Mechanical methods for induction of labour

Which approach is better for labor induction: simultaneous or sequential administration of oxytocin and intrauterine balloon-a systematic review and a meta-analysis

OBJECTIVE

To compare the efficacy of simultaneous and sequential administration of oxytocin and intrauterine balloons in labor induction.

METHODS

The databases of Cochrane Library, Web of Science, PubMed, ClinicalTrials.gov, and Embase were thoroughly searched from their inception to November 2023. Randomized controlled trials (RCTs) investigating the simultaneous and sequential use of oxytocin and intrauterine balloons for labor induction in pregnancy were included. The meta-analysis was performed using RevMan 5.3 statistical software. Heterogeneity among the selected studies was evaluated using the I2 statistic. Dichotomous outcomes were estimated using relative risk (RR) with corresponding 95% confidence intervals (CI), while continuous outcomes were measured as the mean difference (MD).

RESULTS

A total of eight studies, involving a total of 1,315 nulliparous and multiparous women with an unfavorable cervix, were included in the systematic review. Moreover, a subgroup analysis was conducted, separately evaluating nulliparous and multiparous women. Compared with the sequential groups, simultaneous use of oxytocin and intrauterine balloons resulted in a significantly higher rate of delivery within 24h in nulliparas (RR = 1.30, 95%CI:1.04, 1.63, p = 0.02), a higher rate of vaginal delivery within 24h in multiparas (RR = 1.32, 95%CI:1.15,1.51, p < 0.00001), a superior rate of delivery within 12h and a shorter time to delivery in both nulliparas and multiparas. No statistically significant differences were observed in cesarean delivery and maternal and neonatal adverse outcomes between the sequential and simultaneous groups.

CONCLUSIONS

These findings provide support for the simultaneous use of intrauterine balloons and oxytocin during labor induction in nulliparous women. Additionally, this approach may also prove beneficial for multiparas.

Duration of double balloon catheter for patients with prior cesarean: a before and after study

Background

Previous studies that suggest a shorter time from cervical ripening balloon placement to delivery with shorter total balloon placement time have excluded patients with prior cesarean deliveries.

Objective

To evaluate, in patients with a prior history of cesarean delivery undergoing cervical ripening with a double-balloon catheter, whether planned removal of device after 6 vs 12 hours would result in shorter time to vaginal delivery.

Study Design

A before-and-after study was performed after a practice change occurred November 2020, shortening the planned time of double-balloon catheter placement for cervical ripening from 12 to 6 hours. Data were collected via retrospective electronic chart review. Primary outcome was time from balloon placement to vaginal delivery. Secondary outcomes included rates of cesarean delivery, maternal intraamniotic infection, and uterine rupture. Kaplan-Meier curves compared median times to delivery between the groups. A Cox proportional-hazards model was used to adjust for time of balloon placement, number of previous vaginal deliveries, and co-medications used.

Results

From November 2018 to November 2022, 189 analyzable patients with a prior history of cesarean delivery received a double-balloon catheter for cervical ripening during their trial of labor. Patients were separated into pre- and postpolicy change groups (n=91 and 98, respectively). The median time to vaginal delivery for the pregroup was 28 hours (95% CI: 26, 35) and 25 hours (95% CI: 23, 29) for those in the postgroup (P value .052). After adjusting for dilation at time of balloon placement, number of previous vaginal deliveries, and co-medication, the estimated hazard ratio for successful vaginal delivery postpolicy change was 1.89 (95% CI: 1.27, 2.81). There were no differences in rates of secondary outcomes.

Conclusion

In patients with prior cesarean delivery undergoing mechanical cervical ripening with a double-balloon catheter, planned removal at 6 hours compared to 12 hours may result in higher chances of successful vaginal delivery and possibly a shorter time to delivery, without increasing rates of cesarean delivery and intraamniotic infection.

Effect of cervical Bishop score on induction of labor at term in primiparas using Foley catheter balloon: a retrospective study

BACKGROUND

Previous studies had found that the mechanical methods were as effective as pharmacological methods in achieving vaginal delivery. However, whether balloon catheter induction is suitable for women with severe cervical immaturity and whether it will increase the related risks still need to be further explored.

RESEARCH AIM

To evaluate the efficacy and safety of Foley catheter balloon for labor induction at term in primiparas with different cervical scores.

METHODS

A total of 688 primiparas who received cervical ripening with a Foley catheter balloon were recruited in this study. They were divided into 2 groups: Group 1 (Bishop score ≤ 3) and Group 2 (3 < Bishop score < 7). Detailed medical data before and after using of balloon were faithfully recorded.

RESULTS

The cervical Bishop scores of the two groups after catheter placement were all significantly higher than those before (Group 1: 5.49 ± 1.31 VS 2.83 ± 0.39, P<0.05; Group 2: 6.09 ± 1.00 VS 4.45 ± 0.59, P<0.05). The success rate of labor induction in group 2 was higher than that in group 1 (P<0.05). The incidence of intrauterine infection in Group 1 was higher than that in Group 2 (18.3% VS 11.3%, P<0.05).

CONCLUSION

The success rates of induction of labor by Foley catheter balloon were different in primiparas with different cervical conditions, the failure rate of induction of labor and the incidence of intrauterine infection were higher in primiparas with severe cervical immaturity.

Applying Tension to the Transcervical Foley Balloon and Delivery Times in Term Nulliparous Women Undergoing Induction of Labor: A Randomized Controlled Trial

OBJECTIVE

To investigate the effects of applying tension to a transcervical Foley balloon on delivery time in term nulliparous patients undergoing labor induction.

METHODS

This cluster randomized clinical trial included 279 term nulliparous women presenting for labor induction with a plan for cervical ripening through transcervical Foley balloon placement. Participants were assigned to either the tension group (n=138) or the no-tension group (n=141) on the basis of randomized, weekly clusters (26 total clusters). The primary outcome measured was the time from initial Foley balloon insertion to delivery. Secondary outcomes included cesarean delivery rates, peripartum infection, and neonatal intensive care unit (NICU) admission. Our prior data suggested that delivery time in the tension group would be about 1,053 minutes. We estimated a sample size of 260 (130 per group, 26 clusters) on the basis of a 25% difference, power of 80%, and two-sided α of 0.05.

RESULTS

A total of 279 term nulliparous patients were included in the analysis. The median time from Foley placement to delivery was 1,596 minutes (range 430-3,438 minutes) for the tension group and 1,621 minutes (range 488-3,323 minutes) for the no-tension group ( P =.8); similar results were noted for time to vaginal delivery. No significant differences were observed in the secondary outcomes, including the rates of cesarean delivery (34.1% vs 29.8%, P =.7), peripartum infection, and NICU admission, between the two groups.

CONCLUSION

Applying tension to a transcervical Foley balloon in term nulliparous women undergoing labor induction did not significantly reduce delivery time or improve secondary outcomes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT05404776.

Effectiveness of Single Fetal Membrane Sweeping in Reducing Elective Labor Induction for Postdate Pregnancies (38+0 to 40+6 Weeks): A Randomized Controlled Trial

BACKGROUND

 Postdate pregnancy is characterized by a heightened risk for both maternal and perinatal complications. Owing to the risks, clinicians frequently turn to elective labor induction as a management strategy for postdate pregnancies. However, patients are increasingly informed and apprehensive about this approach and its associated risks. This has prompted a search for alternative management methods that may encourage spontaneous labor in pregnant women. One such approach is the use of fetal membrane sweeping, a method known to increase the likelihood of spontaneous labor onset. Yet, it remains unclear whether a single fetal membrane sweeping procedure can effectively reduce the need for elective labor induction in postdate pregnancies while minimizing risks to both the mother and fetus.

OBJECTIVES

The primary objective of this study was to assess the efficacy of a single fetal membrane sweeping procedure conducted between 38+0 and 40+6 weeks of gestation in reducing the rate of elective labor induction among postdate pregnancies at Central Hospital Benin City, Nigeria. Secondary objectives included evaluating the impact of membrane sweeping on maternal and perinatal outcomes.

METHODOLOGY

This open-label superiority randomized controlled study was carried out from June 2020 to March 2021, following ethical approval from the Hospital Management Board (HMB). One hundred and forty eligible participants, without contraindications to vaginal delivery, were randomly assigned to one of two groups. The first group received a single fetal membrane sweeping procedure between 38+0 and 40+6 weeks of gestation, while the control group underwent vaginal examination only to assess the Bishop score. Participants were monitored until delivery. Data analysis was performed. Results were considered statistically significant at p < 0.05.

RESULTS

The implementation of a single fetal membrane sweeping procedure effectively reduced the incidence of elective labor induction. Specifically, the membrane sweep group exhibited a significantly lower rate of elective labor induction compared to the control group (9.0% vs. 27.1%; p=0.0083). Moreover, a substantial proportion of the treatment group (91.4%) experienced spontaneous labor, while the control group reported a rate of 72.9%. The difference was statistically significant (p=0.0054). Notably, the control group exhibited a significantly longer mean time interval from recruitment to delivery (10.67±3.51 days) than the membrane sweeping group (3.64±4.123 days; p<0.05). Also, postdate women in the membrane sweep group were less likely to require cervical ripening with Foley's catheter than those in the control group (33.3% vs. 100%; RR: 0.33 (0.11-1.03); p=0.0057). Still, maternal satisfaction was significantly higher in the membrane-sweeping group (p<0.01). No significant differences were noted across the groups in maternal and neonatal outcomes.

CONCLUSION

In low-risk term pregnancies, a single fetal membrane sweeping procedure is a superior alternative to no membrane sweeping in reducing the rate of elective labor induction for postdate pregnancies and in shortening the duration of term pregnancy.

Twice-daily versus once-daily vaginal dinoprostone gel for induction of labor at term: A randomized controlled trial

OBJECTIVE

The aim of this study was to compare twice-daily versus once-daily administration of intravaginal PGE2 for induction of labor at term. Efficacy, safety, and patient satisfaction were evaluated.

STUDY DESIGN

For this single-center, randomized, comparative, open-label, two-arm, and parallel study, pregnant women with term singleton live pregnancies ≥ 37 weeks of gestation, medical indications for induction of labor, and Bishop score ≤ 6 were randomized to either the control group (induction of labor with PGE2 gel with repeat dose after 24 h) or the experimental group (repeat dose after 12 h). The primary outcome was induction-to-delivery interval time. Secondary outcomes were maternal and neonatal outcomes and patient satisfaction.

RESULTS

In total, 246 women were randomized to the control (n = 121) or experimental groups (n = 125). The mean time for initiation of induction to delivery was 9.4 h shorter in the experimental group compared to controls (p = 0.007). For control vs experimental, there were no differences in tachysystole (19/121, 15.7 % vs 21/124, 16.9 %, respectively; p = 0.79), cesarean section rate (18/121, 14.9 % vs 28/124, 22.6 % respectively; p = 0.12), or other main obstetrical or neonatal outcomes. Patients in the experimental group reported higher satisfaction with their induction (48/96, 50 % with once-daily vs 60/86, 69.8 % with twice-daily; p = 0.010).

CONCLUSION

Among women admitted for induction of labor at term, closer interval of vaginal PGE2 administration was associated with a significantly shorter induction-to-delivery time without increasing maternal or neonatal morbidity. Furthermore, the reduction in induction time was associated with improved patient experience of delivery.

Pre-cervical ripening and hygroscopic cervical dilators in pre-labor induction

INTRODUCTION

Induction of labor (IOL) is becoming a universal topic in Obstetrics, when the risk of continuing a pregnancy outweighs the benefits. Preinduction is a more recent tool to prepare the cervix when the BISHOP-score is low. About one-third of IOL cases require cervical ripening, which is the physical softening, thinning, and dilation of the cervix in preparation for labor and birth. We report a single center experience regarding the use of hygroscopic dilators in the pre-labor phase to obtain cervical ripening before labor induction.

MATERIALS & METHODS

We conducted a retrospective observational study comparing patient records from the Gynecology and Obstetrics Unit in "Santo Stefano" Hospital in Prato, Tuscany. The inclusion criteria for participants were women who had undergone pre-labor induction because of a BISHOP-score < 3. The gestational age of all the pregnant women was at term (> 37 weeks).

RESULTS

From January 2022 to April 2022, a total of 581 women delivered at term of gestational age at the Gynecology and Obstetrics Unit in "Santo Stefano" Hospital. Cervical ripening was necessary for 82 women with a Bishop score < 3 and hygroscopic cervical dilators were used in 35/82 (42.7%) patients. All patients showed a change in Bishop-score upon removal of the dilators. All 35 patients (100%) reported an increase in terms of consistency and dilation of the cervix but not in terms of length. None of the patients reported discomfort during the 24 h that they kept the hygroscopic dilators in place. No patients reported uterine tachysystole on cardiotocographic tracing, vaginal bleeding, rupture of membranes or cervical tears.

CONCLUSIONS

Our results are in line with those in the literature, demonstrating the validity of hygroscopic dilators in cervical maturation of pregnancies at term and their efficacy was again highlighted in terms of both maternal and fetal safety and patient satisfaction.

Membrane Sweeping to Induce Labor in Post-term Pregnant Women: Success Rate and Outcomes

Introduction Membrane sweeping is a mechanical technique by which a clinician inserts one or two fingers into the cervix and detaches the inferior pole of the membranes from the lower uterine segment using a continuous circular sweeping motion. This produces hormones that promote effacement and dilatation, potentially promoting labor. This study aimed to determine the success rate and the outcome of membrane sweeping in postdate pregnant women in Alhasahesa Teaching Hospital.  Methods This prospective descriptive cross-sectional study conducted at Alhashesa Teaching Hospital, Alhashesa, Sudan, between May and October 2022 included all pregnant women at 40 or more weeks of gestation who underwent membrane sweeping to induce labor. We recorded the number of sweeps needed, sweeping-to-delivery interval, mode of delivery, maternal outcome, and fetal outcome (including birth weight, Apgar score at delivery, and the need for neonatal intensive care unit admission [NICU]). Data were collected through patient interviews using a specially designed questionnaire and analyzed using Statistical Package for Social Sciences (SPSS®) software for Windows, Version 26.0 (Armonk, NY: IBM Corp.), Results Membrane sweeping induced labor in 127 postdate women (86.4%). Most of the women in the study (n=138; 93.9%) had no complications, seven (4.8%) had postpartum hemorrhage, one (0.7%) had sepsis, and one (0.7%) was admitted to the intensive care unit. All neonates were alive, and most (n=126; 85.8%) birth weights ranged from 2.5 kg to 3.5 kg. Thirteen (8.8%) neonates weighed less than 2.5 kg, and eight (5.4%) weighed more than 3.5 kg. One hundred thirty-three (90.5%) had Apgar scores <7, eight (5.4%) had Apgar scores under five, and six (4.1%) had Apgar scores of five to six. Seven neonates (4.8%) were admitted to the NICU. Conclusions Membrane sweeping to induce labor has a high success rate, and it can be safe for both the mother and the baby, as it is associated with a low rate of maternal and fetal complications. Additionally, no maternal and/or fetal deaths were reported. A large, controlled study is required to compare its benefits over other methods of induction of labor.

Mechanical methods for induction of labour

BACKGROUND

Mechanical methods were the first methods developed to ripen the cervix and induce labour. During recent decades they have been substituted by pharmacological methods. Potential advantages of mechanical methods, compared with pharmacological methods may include reduction in side effects that could improve neonatal outcomes. This is an update of a review first published in 2001, last updated in 2012.

OBJECTIVES

To determine the effectiveness and safety of mechanical methods for third trimester (> 24 weeks' gestation) induction of labour in comparison with prostaglandin E2 (PGE2) (vaginal and intracervical), low-dose misoprostol (oral and vaginal), amniotomy or oxytocin.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies (9 January 2018). We updated the search in March 2019 and added the search results to the awaiting classification section of the review.

SELECTION CRITERIA

Clinical trials comparing mechanical methods used for third trimester cervical ripening or labour induction with pharmacological methods. Mechanical methods include: (1) the introduction of a catheter through the cervix into the extra-amniotic space with balloon insufflation; (2) introduction of laminaria tents, or their synthetic equivalent (Dilapan), into the cervical canal; (3) use of a catheter to inject fluid into the extra-amniotic space (EASI). This review includes the following comparisons: (1) specific mechanical methods (balloon catheter, laminaria tents or EASI) compared with prostaglandins (different types, different routes) or with oxytocin; (2) single balloon compared to a double balloon; (3) addition of prostaglandins or oxytocin to mechanical methods compared with prostaglandins or oxytocin alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review includes a total of 112 trials, with 104 studies contributing data (22,055 women; 21 comparisons). Risk of bias of trials varied. Overall, the evidence was graded from very-low to moderate quality. All evidence was downgraded for lack of blinding and, for many comparisons, the effect estimates were too imprecise to make a valid judgement.   Balloon versus vaginal PGE2: there may be little or no difference in vaginal deliveries not achieved within 24 hours (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.82 to 1.26; 7 studies; 1685 women; low-quality evidence) and there probably is little or no difference in caesarean sections (RR 1.00, 95% CI 0.92 to 1.09; 28 studies; 6619 women; moderate-quality evidence) between induction of labour with a balloon catheter and vaginal PGE2. A balloon catheter probably reduces the risk of uterine hyperstimulation with fetal heart rate (FHR) changes (RR 0.35, 95% CI 0.18 to 0.67; 6 studies; 1966 women; moderate-quality evidence), serious neonatal morbidity or perinatal death (RR 0.48, 95% CI 0.25 to 0.93; 8 studies; 2757 women; moderate-quality evidence) and may slightly reduce the risk of aneonatal intensive care unit (NICU) admission (RR 0.82, 95% CI 0.65 to 1.04; 3647 women; 12 studies; low-quality evidence). It is uncertain whether there is a difference in serious maternal morbidity or death (RR 0.20, 95% CI 0.01 to 4.12; 4 studies; 1481 women) or five-minute Apgar score < 7 (RR 0.74, 95% CI 0.49 to 1.14; 4271 women; 14 studies) because the quality of the evidence was found to be very low and low, respectively. Balloon versus low-dose vaginal misoprostol: it is uncertain whether there is a difference in vaginal deliveries not achieved within 24 hours between induction of labour with a balloon catheter and vaginal misoprostol (RR 1.09, 95% CI 0.85 to 1.39; 340 women; 2 studies; low-quality evidence). A balloon catheter probably reduces the risk of uterine hyperstimulation with FHR changes (RR 0.39, 95% CI 0.18 to 0.85; 1322 women; 8 studies; moderate-quality evidence) but may increase the risk of a caesarean section (RR 1.28, 95% CI 1.02 to 1.60; 1756 women; 12 studies; low-quality evidence). It is uncertain whether there is a difference in serious neonatal morbidity or perinatal death (RR 0.58, 95% CI 0.12 to 2.66; 381 women; 3 studies), serious maternal morbidity or death (no events; 4 studies, 464 women), both very low-quality evidence, and five-minute Apgar score < 7 (RR 1.00, 95% CI 0.50 to 1.97; 941 women; 7 studies) and NICU admissions (RR 1.00, 95% CI 0.61 to 1.63; 1302 women; 9 studies) both low-quality evidence. Balloon versus low-dose oral misoprostol: a balloon catheter probably increases the risk of a vaginal delivery not achieved within 24 hours (RR 1.28, 95% CI 1.13 to 1.46; 782 women, 2 studies, and probably slightly increases the risk of a caesarean section (RR 1.17, 95% CI 1.04 to 1.32; 3178 women; 7 studies; both moderate-quality evidence) when compared to oral misoprostol. It is uncertain whether there is a difference in uterine hyperstimulation with FHR changes (RR 0.81, 95% CI 0.48 to 1.38; 2033 women; 2 studies), serious neonatal morbidity or perinatal death (RR 1.11, 95% CI 0.60 to 2.06; 2627 women; 3 studies), both low-quality evidence, serious maternal morbidity or death (RR 0.50, 95% CI 0.05 to 5.52; 2627 women; 3 studies), very low-quality evidence, five-minute Apgar scores < 7 (RR 0.71, 95% CI 0.38 to 1.32; 2693 women; 4 studies) and NICU admissions (RR 0.82, 95% CI 0.58 to 1.17; 2873 women; 5 studies) both low-quality evidence.

AUTHORS' CONCLUSIONS

Low- to moderate-quality evidence shows mechanical induction with a balloon is probably as effective as induction of labour with vaginal PGE2. However, a balloon seems to have a more favourable safety profile. More research on this comparison does not seem warranted. Moderate-quality evidence shows a balloon catheter may be slightly less effective as oral misoprostol, but it remains unclear if there is a difference in safety outcomes for the neonate. When compared to low-dose vaginal misoprostol, low-quality evidence shows a balloon may be less effective, but probably has a better safety profile. Future research could be focused more on safety aspects for the neonate and maternal satisfaction.

Safety and efficacy of double-balloon catheter for cervical ripening: a Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

Various methods are used for cervical ripening during the induction of labor. Mechanical and pharmacological methods are commonly used for cervical ripening. A double-balloon catheter was specifically developed to ripen the cervix and induce labor; however, the efficacy of the double-balloon catheter in cervical ripening compared to other methods is unknown.

METHODS

We searched five databases and performed a Bayesian network meta-analysis. Six interventions (double-balloon catheter, Foley catheter, oral misoprostol, vaginal misoprostol, dinoprostone, and double-balloon catheter combined with oral misoprostol) were included in the search. The primary outcomes were cesarean delivery rate and time from intervention-to-birth. The secondary outcomes were as follows: Bishop score increment; achieving a vaginal delivery within 24 h; uterine hyperstimulation with fetal heart rate changes; need for oxytocin augmentation; instrumental delivery; meconium staining; chorioamnionitis; postpartum hemorrhage; low Apgar score; neonatal intensive care unit admission; and arterial pH.

RESULTS

Forty-eight randomized controlled trials involving 11,482 pregnant women were identified. The cesarean delivery rates of the cervical ripening with a double-balloon catheter and oral misoprostol, oral misoprostol, and vaginal misoprostol were significantly lower than cervical ripening with a Foley catheter (OR = 0.48, 95% CI: 0.23-0.96; OR = 0.74, 95% CI: 0.58-0.93; and OR = 0.79, 95% CI: 0.64-0.97, respectively; all P < 0.05). The time from intervention-to-birth of vaginal misoprostol was significantly shorter than the other five cervical ripening methods. Vaginal misoprostol and oral misoprostol increased the risk of uterine hyperstimulation with fetal heart rate changes compared to a Foley catheter. A double-balloon catheter with or without oral misoprostol had similar outcomes, including uterine hyperstimulation with fetal heart rate changes compared to a Foley catheter.

CONCLUSION

Double-balloon catheter did not show superiority when compared with other single method in primary and secondary outcomes of labor induction. The combination of double-balloon catheter with oral misoprostol was significantly reduced the rate of cesarean section compared to Foley catheter without increased risk of uterine hyperstimulation with fetal heart rate changes, which was shown in oral or vaginal misoprostol.

Cross-Cultural Adaptation and Psychometric Properties of the French Version of the EXIT to Measure Women’s Experiences of Induction of Labor

Background: In France, more than 20% of women require induction of labor (IOL), which can be psychologically and emotionally challenging for patients. It is important to assess how they feel about their IOL experiences. Our aim was to cross-culturally adapt and evaluate the psychometric properties of a French version of the EXIT to assess women’s experiences of IOL. Methods: The EXIT was cross-culturally adapted by conducting forward and backward translations following international guidelines. A cross-sectional study was conducted to assess the psychometric properties of the ten French EXIT items: data completeness, factor analysis, internal consistency, score distribution, floor and ceiling effects, inter-subscale correlations, convergent validity, and test–retest reliability. Results: The EXIT was successfully cross-culturally adapted to the French context and any IOL method. The results obtained from 163 patients requiring IOL showed good acceptability. Exploratory factor analysis resulted in a three-factor solution with subscales reflecting the experiential aspects of time taken to give birth, discomfort with IOL, and subsequent contractions. Good internal consistency (Cronbach’s alpha or Spearman correlation coefficients ranging from 0.55 to 0.84) and good test–retest reliability (intraclass correlation coefficients ranging from 0.66 to 0.85) for the three identified subscales were found. Conclusions: The ten-item French EXIT is a valid and reliable instrument for the self-assessment of women’s experiences of IOL in the three weeks following delivery for any method of IOL used. As a patient-reported outcome measure, it would allow the comparison of experiential outcomes across IOL studies in order to include women’s preferences in decisions regarding their care.

A snapshot of women’s and clinicians’ perceptions of the double balloon catheter for induction of labor

INTRODUCTION

Induction of labor (IOL) is rising globally and is growing steadily in the state of New South Wales, Australia. There are numerous methods of induction of labor, including the double balloon catheter (DBC). There is minimal evidence on women’s attitudes and experiences and clinician’s opinions on the use of the DBC. This study aims to explore the views regarding DBC insertion and effectiveness from women induced with a DBC and clinicians involved in the catheter insertion and care.

METHODS

This study is a descriptive survey of two prospective, de-identified, self-reported questionnaires which were completed in 2016. One questionnaire was administered to term pregnant women that were admitted to the antenatal ward post IOL, and the other was completed by midwives and obstetric doctors working in the ward at the time.

RESULTS

The DBC appeared to be a well-accepted method of cervical ripening among women (61%) and clinicians (>82%). Success of DBC to achieve an artificial rupture of membrane post removal, directly correlates to women’s acceptance (61%). While most clinicians (59–67%) perceived insertion of DBC in an outpatient setting and then women discharged home was appropriate, only 13% of women were in favor. On the logistics of the procedure in respect to insertion and removal of the DBC, there were differences of opinion, with only 43% of women, 77% of midwives and 33% of doctors stating that the timing of insertion and removal needed to be improved.

CONCLUSIONS

This study highlights the need to undertake qualitative research to further explore women’s views and perceptions on IOL in order to ensure that clinical practice is woman-centered and evidenced-based, and to guide policy and protocol.

Outcome of Induction of Labor with Foley's Catheter in Women with Previous One Cesarean Section with Unfavorable Cervix: An Experience From a Tertiary Care Institute in South India

BACKGROUND

Induction of labor in women with previous cesarean section is associated by the fear of scar rupture, resulting in high rates of repeat scheduled cesarean section. Mechanical methods are being advocated as a safe method. We present our experience of vaginal birth rates and safety profile with single-balloon Foley's catheter for induction of labor in women with previous one cesarean section.

METHODS

We studied 96 women admitted in Women and Children Hospital JIPMER, India, with a previous cesarean section at term having unfavorable cervix and undergoing induction of labor. Foley's catheter inflated to 60 ml was used for cervical ripening for 24 h followed by strict oxytocin infusion protocol.

RESULTS

The mean Bishop score before induction of labor was 3.3 ± 0.88. Ripening with Foley's catheter resulted in mean improvement in the Bishop score by 2.56 ± 0.67. Forty-seven percent women spontaneously expelled the Foley's catheter, and 53.1% achieved contractions spontaneously. The successful vaginal birth rate was 40%. Emergency caesarean section was more likely in women with poor post ripening Bishop score, meconium stained liquor and abnormal fetal heart rate pattern during labour. There was one scar dehiscence, one neonate with low Apgar score. There was no rupture uterus.

CONCLUSION

Induction of labor with Foley's catheter resulted in a 40% successful vaginal birth rate and was found to be safe with only one scar dehiscence and no perinatal or maternal mortality. There was no perinatal or maternal mortality.

Low-dose oral misoprostol for induction of labour

BACKGROUND

Misoprostol given orally is a commonly used labour induction method. Our Cochrane Review is restricted to studies with low-dose misoprostol (initially ≤ 50 µg), as higher doses pose unacceptably high risks of uterine hyperstimulation.

OBJECTIVES

To assess the efficacy and safety of low-dose oral misoprostol for labour induction in women with a viable fetus in the third trimester of pregnancy.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov,  the WHO International Clinical Trials Registry Platform (14 February 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials comparing low-dose oral misoprostol (initial dose ≤ 50 µg) versus placebo, vaginal dinoprostone, vaginal misoprostol, oxytocin, or mechanical methods; or comparing oral misoprostol protocols (one- to two-hourly versus four- to six-hourly; 20 µg to 25 µg versus 50 µg; or 20 µg hourly titrated versus 25 µg two-hourly static).

DATA COLLECTION AND ANALYSIS

Using Covidence, two review authors independently screened reports, extracted trial data, and performed quality assessments. Our primary outcomes were vaginal birth within 24 hours, caesarean section, and hyperstimulation with foetal heart changes.

MAIN RESULTS

We included 61 trials involving 20,026 women. GRADE assessments ranged from moderate- to very low-certainty evidence, with downgrading decisions based on imprecision, inconsistency, and study limitations. Oral misoprostol versus placebo/no treatment (four trials; 594 women) Oral misoprostol may make little to no difference in the rate of caesarean section (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.59 to 1.11; 4 trials; 594 women; moderate-certainty evidence), while its effect on uterine hyperstimulation with foetal heart rate changes is uncertain (RR 5.15, 95% CI 0.25 to 105.31; 3 trials; 495 women; very low-certainty evidence). Vaginal births within 24 hours was not reported. In all trials, oxytocin could be commenced after 12 to 24 hours and all women had pre-labour ruptured membranes. Oral misoprostol versus vaginal dinoprostone (13 trials; 9676 women) Oral misoprostol probably results in fewer caesarean sections (RR 0.84, 95% CI 0.78 to 0.90; 13 trials, 9676 women; moderate-certainty evidence). Subgroup analysis indicated that 10 µg to 25 µg (RR 0.80, 95% CI 0.74 to 0.87; 9 trials; 8652 women) may differ from 50 µg (RR 1.10, 95% CI 0.91 to 1.34; 4 trials; 1024 women) for caesarean section. Oral misoprostol may decrease vaginal births within 24 hours (RR 0.93, 95% CI 0.87 to 1.00; 10 trials; 8983 women; low-certainty evidence) and hyperstimulation with foetal heart rate changes (RR 0.49, 95% CI 0.40 to 0.59; 11 trials; 9084 women; low-certainty evidence). Oral misoprostol versus vaginal misoprostol (33 trials; 6110 women) Oral use may result in fewer vaginal births within 24 hours (average RR 0.81, 95% CI 0.68 to 0.95; 16 trials, 3451 women; low-certainty evidence), and less hyperstimulation with foetal heart rate changes (RR 0.69, 95% CI 0.53 to 0.92, 25 trials, 4857 women, low-certainty evidence), with subgroup analysis suggesting that 10 µg to 25 µg orally (RR 0.28, 95% CI 0.14 to 0.57; 6 trials, 957 women) may be superior to 50 µg orally (RR 0.82, 95% CI 0.61 to 1.11; 19 trials; 3900 women). Oral misoprostol probably does not increase caesarean sections overall (average RR 1.00, 95% CI 0.86 to 1.16; 32 trials; 5914 women; low-certainty evidence) but likely results in fewer caesareans for foetal distress (RR 0.74, 95% CI 0.55 to 0.99; 24 trials, 4775 women). Oral misoprostol versus intravenous oxytocin (6 trials; 737 women, 200 with ruptured membranes) Misoprostol may make little or no difference to vaginal births within 24 hours (RR 1.12, 95% CI 0.95 to 1.33; 3 trials; 466 women; low-certainty evidence), but probably results in fewer caesarean sections (RR 0.67, 95% CI 0.50 to 0.90; 6 trials; 737 women; moderate-certainty evidence). The effect on hyperstimulation with foetal heart rate changes is uncertain (RR 0.66, 95% CI 0.19 to 2.26; 3 trials, 331 women; very low-certainty evidence). Oral misoprostol versus mechanical methods (6 trials; 2993 women) Six trials compared oral misoprostol to transcervical Foley catheter. Misoprostol may increase vaginal birth within 24 hours (RR 1.32, 95% CI 0.98 to 1.79; 4 trials; 1044 women; low-certainty evidence), and probably reduces the risk of caesarean section (RR 0.84, 95% CI 0.75 to 0.95; 6 trials; 2993 women; moderate-certainty evidence). There may be little or no difference in hyperstimulation with foetal heart rate changes (RR 1.31, 95% CI 0.78 to 2.21; 4 trials; 2828 women; low-certainty evidence). Oral misoprostol one- to two-hourly versus four- to six-hourly (1 trial; 64 women) The evidence on hourly titration was very uncertain due to the low numbers reported. Oral misoprostol 20 µg hourly titrated versus 25 µg two-hourly static (2 trials; 296 women) The difference in regimen may have little or no effect on the rate of vaginal births in 24 hours (RR 0.97, 95% CI 0.80 to 1.16; low-certainty evidence). The evidence is of very low certainty for all other reported outcomes.

AUTHORS' CONCLUSIONS

Low-dose oral misoprostol is probably associated with fewer caesarean sections (and therefore more vaginal births) than vaginal dinoprostone, and lower rates of hyperstimulation with foetal heart rate changes. However, time to birth may be increased, as seen by a reduced number of vaginal births within 24 hours. Compared to transcervical Foley catheter, low-dose oral misoprostol is associated with fewer caesarean sections, but equivalent rates of hyperstimulation. Low-dose misoprostol given orally rather than vaginally is probably associated with similar rates of vaginal birth, although rates may be lower within the first 24 hours. However, there is likely less hyperstimulation with foetal heart changes, and fewer caesarean sections performed due to foetal distress. The best available evidence suggests that low-dose oral misoprostol probably has many benefits over other methods for labour induction. This review supports the use of low-dose oral misoprostol for induction of labour, and demonstrates the lower risks of hyperstimulation than when misoprostol is given vaginally. More trials are needed to establish the optimum oral misoprostol regimen, but these findings suggest that a starting dose of 25 µg may offer a good balance of efficacy and safety.

Outpatient Induction of Labor - Are Balloon Catheters an Appropriate Method?

As the number of labor inductions in high-income countries has steadily risen, hospital costs and the additional burden on obstetric staff have also increased. Outpatient induction of labor is therefore becoming increasingly important. It has been estimated that 20 - 50% of all pregnant women requiring induction would be eligible for outpatient induction. The use of balloon catheters in patients with an unripe cervix has been shown to be an effective and safe method of cervical priming. Balloon catheters are as effective as the vaginal administration of prostaglandin E 2 or oral misoprostol. The advantage of using a balloon catheter is that it avoids uterine hyperstimulation and monitoring is less expensive. This makes balloon catheters a suitable option for outpatient cervical ripening. Admittedly, intravenous administration of oxytocin to induce or augment labor is required in approximately 75% of cases. Balloon catheters are not associated with a higher risk of maternal and neonatal infection compared to vaginal PGE 2 . Low-risk pregnancies (e.g., post-term pregnancies, gestational diabetes) are suitable for outpatient cervical ripening with a balloon catheter. The data for high-risk pregnancies are still insufficient. The following conditions are recommended when considering an outpatient approach: strict selection of appropriate patients (singleton pregnancy, cephalic presentation, intact membranes), CTG monitoring for 20 - 40 minutes after balloon placement, the patient must be given detailed instructions about the indications for immediate readmission to hospital, and 24-hour phone access to the hospital must be ensured. According to reviewed studies, the balloon catheter remained in place between 12 hours ("overnight") and 24 hours. The most common reason for readmission to hospital was expulsion of the balloon catheter. The advantages of outpatient versus inpatient induction of cervical ripening with a balloon catheter were the significantly shorter hospital stay, the lower costs, and higher patient satisfaction, with both procedures having been shown to be equally effective. Complication rates (e.g., vaginal bleeding, severe pain, uterine hyperstimulation syndrome) during the cervical ripening phase are low (0.3 - 1.5%); severe adverse outcomes (e.g., placental abruption) have not been reported. Compared to inpatient induction of labor using vaginal PGE 2 , outpatient cervical ripening using a balloon catheter had a lower rate of deliveries/24 hours and a significantly higher need for oxytocin; however, hospital stay was significantly shorter, frequency of pain during the cervical ripening phase was significantly lower, and patients' duration of sleep was longer. A randomized controlled study comparing outpatient cervical priming with a balloon catheter with outpatient or inpatient induction of labor with oral misoprostol would be of clinical interest.

Implementation of Evidence-Based Cervical Ripening Protocol: Outcomes and Next Steps

Objective  A prominent randomized controlled trial demonstrated that low-dose misoprostol with the concurrent cervical Foley shortened the median time to delivery when compared with either method alone. Our study aims to address implementation of this protocol and evaluate its impact on time to delivery. Study Design  This was a retrospective before-and-after study of nulliparous women who delivered nonanomalous, term, singletons at the University of California San Francisco (UCSF) in two separate 2-year periods before and after changes in UCSF's cervical ripening protocol. The primary outcome was time from first misoprostol dose to delivery. Results  A total of 1,496 women met inclusion criteria, with 698 in the preimplementation group and 798 in the postimplementation group. There were no statistically significant differences in time to delivery (29 vs. 30 hours, p  = 0.69), rate of cesarean delivery (30 vs. 26%, p  = 0.09), or cesarean delivery for fetal indications (11 vs. 8%, p  = 0.15) between the groups. Conclusion  Implementing evidence-based low-dose misoprostol with the concurrent cervical Foley did not change the time to delivery, time to vaginal-delivery, or likelihood of vaginal delivery in our population. This may be due to differences in labor management practices and incomplete fidelity to the protocol. Real-world effectiveness of these interventions will vary and should be considered when choosing an induction method.

Outpatient balloon catheter vs inpatient prostaglandin for induction of labour (OBLIGE): a randomised controlled trial

Background

Approximately one in four pregnant women undergo an induction of labour. The purpose of this study is to investigate the clinical effectiveness, safety, and cost-effectiveness for mothers and babies of two methods of cervical ripening – inpatient care for women starting induction with vaginal prostaglandin E2 hormones, or allowing women to go home for 18 to 24 h after starting induction with a single-balloon catheter.

Methods/design

This is a multi-centre randomised controlled trial in New Zealand. Eligible pregnant women, with a live singleton baby in a cephalic presentation who undergo a planned induction of labour at term, will be randomised to outpatient balloon-catheter induction or in-hospital prostaglandin induction. The primary outcome is caesarean section rate. To detect a 24% relative risk reduction in caesarean rate from a baseline of 24.8%, with 80% power and 5% type 1 error, will require 1552 participants in a one to one ratio.

Discussion

If outpatient balloon-catheter induction reduces caesarean section rates, has additional clinical benefits, and is safe, cost-effective, and acceptable to women and clinicians, we anticipate change in induction of labour practice around the world. We think that home-based balloon-catheter induction will be welcomed as part of a patient-centred labour-induction care package for pregnant women.

Trial registration

Australia New Zealand Clinical Trials Registry (ANZCTR), ACTRN: 12616000739415. Registered on 6 June 2016.

Comparison of the myometrial transcriptome from singleton and twin pregnancies by RNA-Seq

Preterm birth is recognized as the primary cause of infant mortality worldwide. Twin pregnancies are significantly more at risk of preterm birth than singleton pregnancies. A greater understanding of why this is and better modes of treatment and prevention are needed. Key to this is determining the differing pathophysiological mechanisms of preterm birth in twins, including the role of the myometrium and premature uterine contraction. We performed RNA sequencing (RNA-Seq) of human myometrium from singleton and twin pregnancies at term (> 37+0 weeks) and preterm (< 37+0 weeks), collected during pre-labour Caesarean Section. RNA-Seq libraries were prepared from polyA-selected RNA and sequenced on the Illumina HiSeq 4000 platform. Differentially expressed genes (DEGs), GO (Gene Ontology) and KEGG (Kyoto Encyclopedia of Genes and Genomes) pathway enrichment were conducted using R software. Significance was determined with a false discovery rate-adjusted P value of <0.05. Only 3 DEGs were identified between gestational age-matched singleton and twin myometrium and only 1 DEG identified between singleton term and twin preterm tissues. Comparison of singleton preterm myometrium with twin term myometrium however, revealed 75 down-regulated and 24 up-regulated genes in twin myometrium. This included genes associated with inflammation and immune response, T cell maturation and differentiation and steroid biosynthesis. GO and KEGG enrichment analyses for biologically relevant processes and functions also revealed several terms related to inflammation and immune response, as well as cytokine-cytokine receptor interaction and chemokine receptor signalling. Data indicate that little or no differences exist in the transcriptome of singleton and twin myometrium when matched for gestational age. The significant up- and down-regulation of genes identified between preterm singleton and twin myometrium at term may point to transcriptome changes associated with the chronic levels of uterine stretch in twin pregnancy or genes associated with the myometrium transitioning to labour onset.

Oral misoprostol, low dose vaginal misoprostol, and vaginal dinoprostone for labor induction: Randomized controlled trial

OBJECTIVE

To compare effectiveness and safety of oral misoprostol (50 μg every four hours as needed), low dose vaginal misoprostol (25 to 50 μg every six hours as needed), and our established dinoprostone vaginal gel (one to two mg every six hours as needed) induction.

MATERIALS AND METHODS

Consenting women with a live term single cephalic fetus for indicated labor induction were randomized (3N = 511). Prior uterine surgery or non-reassuring fetal surveillance were exclusions. Concealed computer generated randomization was stratified and blocked. Newborns were assessed by a team unaware of group assignment. The primary outcome was time from induction at randomization to vaginal birth for initial parametric analysis. Sample size was based on mean difference of 240 minutes with α2 = 0.05 and power 95%. Non-parametric analysis was also pre-specified ranking cesareans as longest vaginal births.

RESULTS

Enrollment was from April 1999 to December 2000. Demographics were similar across groups. Analysis was by intent to treat, with no loss to follow up. Mean time (±SD) to vaginal birth was 1356 (±1033) minutes for oral misoprostol, 1530 (±3249) minutes for vaginal misoprostol, and 1208 (±613) minutes for vaginal dinoprostone (P = 0.46, ANOVA). Median times to vaginal birth were 1571, 1339, and 1451 minutes respectively (P = 0.46, Kruskal-Wallis). Vaginal births occurred within 24 hours in 44.9, 53.5 and 47.7% respectively (P = 0.27, χ2). There were no significant differences in Kaplan Meier survival analyses, cesareans, adverse effects, or maternal satisfaction. The newborn who met birth asphyxia criteria received vaginal misoprostol, as did. all three other newborns with cord artery pH<7.0 (P = 0.04, Fisher Exact).

CONCLUSION

There was no significant difference in effectiveness of the three groups. Profound newborn acidemia, though infrequent, occurred only with low dose vaginal misoprostol.

A lariat-based dilatation device for hysteroscopy: an in vitro study

Background

Hysteroscopy is regarded as the golden standard for the therapeutic and diagnostic methods of many uterine diseases. Carbon dioxide, normal saline and pharmaceuticals are generally used to dilate the uterus to obtain enough operating space and clear vision during the surgery. However, these methods often cause various syndromes.

Methods

In this study, we designed a novel mechanical dilator and operating system. The dilator contains a structure with a diameter of 9 mm in its initial status to pass through the narrow cervix after initial cervical dilation by cervical dilator and then its diameter can be expanded up to 60 mm in the working status to achieve a favorable operating space. The operating system is composed of an endoscope and the surgical instrument driving tube. The endoscope was motioned by pre-bent hyperelastic wires and the surgical instrument was driven by a pre-bent driving tube. To obtain the parameters for successful expansion and operation, the relationships between the tension, the diameter of the dilator and the visual and operating space of the operating system were analyzed in detail. On the basis of the obtained parameters, the surgical experiment was performed and the experimental results demonstrated the ability of this dilator to expand and the ability of the operator to operate in small spaces for hysteroscopy.

Results

According to the achieved results, the dilator could support the inner wall of the simulated organ to act like a cage, so that the space in the cage was large enough. The operating system can thrust into the intracavity of the simulated uterus through the channel (with a diameter of 6 mm) of the dilator to search for and excise the raised polyp.

Conclusions

It can be concluded that the proposed dilator and operating system can be efficiently applied in organ expansion and operation in hysteroscopy.

MEchanical DIlatation of the Cervix-- in a Scarred uterus (MEDICS): the study protocol of a randomised controlled trial comparing a single cervical catheter balloon and prostaglandin PGE2 for cervical ripening and labour induction following caesarean delivery

INTRODUCTION

Labour induction in women with a previous caesarean delivery currently uses vaginal prostaglandin E2 (PGE2), which carries the risks of uterine hyperstimulation and scar rupture. We aim to compare the efficacy of mechanical labour induction using a transcervically applied Foley catheter balloon (FCB) with PGE2 in affected women attempting trial of labour after caesarean (TOLAC).

METHODS AND ANALYSIS

This single-centre non-inferiority prospective, randomised, open, blinded-endpoint study conducted at an academic maternity unit in Singapore will recruit a total of 100 women with one previous uncomplicated caesarean section and no contraindications to vaginal delivery. Eligible consented participants with term singleton pregnancies and unfavourable cervical scores (≤5) requiring labour induction undergo stratified randomisation based on parity and are assigned either FCB (n=50) or PGE2 (n=50). Treatments are applied for up to 12 hours with serial monitoring of the mother and the fetus and serial assessment for improved cervical scores. If the cervix is still unfavourable, participants are allowed a further 12 hours' observation for cervical ripening. Active labour is initiated by amniotomy at cervical scores of ≥6. The primary outcome is the rate of change in the cervical score, and secondary outcomes include active labour within 24 hours of induction, vaginal delivery, time-to-delivery interval and uterine hyperstimulation. All analyses will be intention-to-treat. The data generated in this trial may guide a change in practice towards mechanical labour induction if this proves efficient and safer for women attempting TOLAC compared with PGE2, to improve labour management in this high-risk population.

ETHICS AND DISSEMINATION

Ethical approval is granted by the Domain Specific Review Board (Domain D) of the National Healthcare Group, Singapore. All adverse events will be reported within 24 hours of notification for assessment of causality. Data will be published and will be available for future meta-analyses.

TRIAL REGISTRATION NUMBER

NCT03471858; Pre-results.

A comparison between induction of labor with 3 methods of titrated oral misoprostol, constant dose of oral misoprostol and Foley catheter with extra amniotic saline infusion (EASI), in women with unfavorable cervix

Background: Different methods of cervical ripening and induction of labor have been used in the cases of unfavorable cervix with different levels of success, but no method has been found to be the best option. The purpose of the present study was to find the effects and side effects of three different methods of cervical ripening and induction of labor. These three methods were oral titrated misoprostol, constant dose of oral misoprostol and Foley catheter with extra-amniotic saline infusion.

Methods: This clinical trial was performed on women with unfavorable cervix who had been admitted in Akbarabadi Teaching Hospital for induction of labor and had bishop score of less than six; between March 2014- March 2015. The eligible women were assigned into three groups. In titrated oral misoprostol group (n=33), titrated solution of misoprostol, and in oral misoprostol group (n=33), 50µg oral misoprostol every four hours and in Foley catheter group (n=50), Foley catheter with extra-amniotic saline infusion were administered. The main outcome was the number of vaginal deliveries during the first 24 hours. In addition, number of cesarean deliveries and adverse effects were compared between the three groups. The obtained data were analyzed using SPSS 18 software. Data analysis was performed according to the intention to treat principle. Chi-square test, Fisher Exact test, Student ttest, and Mann-Whitney U test, were used for comparing data. P-value≤0.05 was considered statistically significant.

Results: The three groups did not have any significant difference according to maternal age, gestational age at the time of admission, gravidity, parity, and primary Bishop Score. There was no significant difference between the three groups for the main outcome, which was vaginal delivery during the first 24 hours (p=0.887). There was no significant difference between the three groups according to hypertonicity, uterine hyperstimulation, meconium passage, non-reassuring fetal heart rate, neonatal Apgar score in minutes one and 5, and mean duration of beginning the intervention up to delivery. However, uterine tachysystole and NICU admission were more in the group to whom the titrated solution of misoprostol was administered (p=0.002 and p=0.037 respectively). The number of cesarean deliveries due to failure to progress was higher in the EASI group. However, EASI group showed the least number of none-reassuring fetal heart rate between the three groups. Meconium passage was more in the titrated misoprostol group, but the difference was not significant.

Conclusion: All three methods are appropriate methods for induction of labor in the cases of unfavorable cervix; and choosing each method depends on the expertise of labor staff, accessibility to the medications, cost, and taking care for monitoring the patients and adverse effects.

Mechanical methods for induction of labour

BACKGROUND

Mechanical methods were the first methods developed to ripen the cervix and induce labour. During recent decades they have been substituted by pharmacological methods. Potential advantages of mechanical methods, compared with pharmacological methods may include reduction in side effects that could improve neonatal outcomes. This is an update of a review first published in 2001, last updated in 2012.

OBJECTIVES

To determine the effectiveness and safety of mechanical methods for third trimester (> 24 weeks' gestation) induction of labour in comparison with prostaglandin E2 (PGE2) (vaginal and intracervical), low-dose misoprostol (oral and vaginal), amniotomy or oxytocin.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies (9 January 2018). We updated the search in March 2019 and added the search results to the awaiting classification section of the review.

SELECTION CRITERIA

Clinical trials comparing mechanical methods used for third trimester cervical ripening or labour induction with pharmacological methods.Mechanical methods include: (1) the introduction of a catheter through the cervix into the extra-amniotic space with balloon insufflation; (2) introduction of laminaria tents, or their synthetic equivalent (Dilapan), into the cervical canal; (3) use of a catheter to inject fluid into the extra-amniotic space (EASI).This review includes the following comparisons: (1) specific mechanical methods (balloon catheter, laminaria tents or EASI) compared with prostaglandins (different types, different routes) or with oxytocin; (2) single balloon compared to a double balloon; (3) addition of prostaglandins or oxytocin to mechanical methods compared with prostaglandins or oxytocin alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review update includes a total of 113 trials (22,373 women) contributing data to 21 comparisons. Risk of bias of trials varied. Overall, the evidence was graded from very-low to moderate quality. All evidence was downgraded for lack of blinding and, for many comparisons, the effect estimates were too imprecise to make a valid judgement.Balloon versus vaginal PGE2: there may be little or no difference in vaginal deliveries not achieved within 24 hours (average risk ratio (RR) 1.01, 95% confidence interval (CI) 0.82 to 1.26; 7 studies; 1685 women; I² = 79%; low-quality evidence) and there probably is little or no difference in caesarean sections (RR 1.00, 95% CI 0.92 to 1.09; 28 studies; 6619 women; moderate-quality evidence) between induction of labour with a balloon catheter and vaginal PGE2. A balloon catheter probably reduces the risk of uterine hyperstimulation with fetal heart rate (FHR) changes (RR 0.35, 95% CI 0.18 to 0.67; 6 studies; 1966 women; moderate-quality evidence), serious neonatal morbidity or perinatal death (RR 0.48, 95% CI 0.25 to 0.93; 8 studies; 2757 women; moderate-quality evidence) and may slightly reduce the risk of aneonatal intensive care unit (NICU) admission (RR 0.82, 95% CI 0.65 to 1.04; 3647 women; 12 studies; low-quality evidence). It is uncertain whether there is a difference in serious maternal morbidity or death (RR 0.20, 95% CI 0.01 to 4.12; 4 studies; 1481 women) or five-minute Apgar score < 7 (RR 0.74, 95% CI 0.49 to 1.14; 4271 women; 14 studies) because the quality of the evidence was found to be very low and low, respectively.Balloon versus low-dose vaginal misoprostol: it is uncertain whether there is a difference in vaginal deliveries not achieved within 24 hours between induction of labour with a balloon catheter and vaginal misoprostol (RR 1.09, 95% CI 0.85 to 1.39; 340 women; 2 studies; low-quality evidence). A balloon catheter probably reduces the risk of uterine hyperstimulation with FHR changes (RR 0.39, 95% CI 0.18 to 0.85; 1322 women; 8 studies; moderate-quality evidence) but may increase the risk of a caesarean section (average RR 1.28, 95% CI 1.02 to 1.60; 1756 women; 12 studies; I² = 45%; low-quality evidence). It is uncertain whether there is a difference in serious neonatal morbidity or perinatal death (RR 0.58, 95% CI 0.12 to 2.66; 381 women; 3 studies), serious maternal morbidity or death (no events; 4 studies, 464 women), both very low-quality evidence, and five-minute Apgar score < 7 (RR 1.00, 95% CI 0.50 to 1.97; 941 women; 7 studies) and NICU admissions (RR 1.00, 95% CI 0.61 to 1.63; 1302 women; 9 studies) both low-quality evidence.Balloon versus low-dose oral misoprostol: a balloon catheter probably increases the risk of a vaginal delivery not achieved within 24 hours (RR 1.28, 95% CI 1.13 to 1.46; 782 women, 2 studies, and probably slightly increases the risk of a caesarean section (RR 1.17, 95% CI 1.04 to 1.32; 3178 women; 7 studies; both moderate-quality evidence) when compared to oral misoprostol. It is uncertain whether there is a difference in uterine hyperstimulation with FHR changes (RR 0.81, 95% CI 0.48 to 1.38; 2033 women; 2 studies), serious neonatal morbidity or perinatal death (RR 1.11, 95% CI 0.60 to 2.06; 2627 women; 3 studies), both low-quality evidence, serious maternal morbidity or death (RR 0.50, 95% CI 0.05 to 5.52; 2627 women; 3 studies), very low-quality evidence, five-minute Apgar scores < 7 (RR 0.71, 95% CI 0.38 to 1.32; 2693 women; 4 studies) and NICU admissions (RR 0.82, 95% CI 0.58 to 1.17; 2873 women; 5 studies) both low-quality evidence.

AUTHORS' CONCLUSIONS

Low- to moderate-quality evidence shows mechanical induction with a balloon is probably as effective as induction of labour with vaginal PGE2. However, a balloon seems to have a more favourable safety profile. More research on this comparison does not seem warranted.Moderate-quality evidence shows a balloon catheter may be slightly less effective as oral misoprostol, but it remains unclear if there is a difference in safety outcomes for the neonate. When compared to low-dose vaginal misoprostol, low-quality evidence shows a balloon may be less effective, but probably has a better safety profile.Future research could be focused more on safety aspects for the neonate and maternal satisfaction.

INADEQUATE ADHERENCE TO THE RECOMMENDATIONS REGARDING LABOR INDUCTION AS A TRIGGER OF CESAREAN SECTION IN WOMEN WITH SINGLE, TERM PREGNANCY. A DESCRIPTIVE STUDY

OBJECTIVE

To describe the characteristics of the labor induction process associated with the excess number of cesarean sections in women subjected to this intervention.

METHODS

Descriptive historical. cohort that included pregnant women without a history of previous cesarean section, with single term pregnancy and cephalic presentation who were subjected to labor induction in a Level III com- plexity hospital in Medellín, Colombia, during the time period between May 2015 and October 2016. Consecutive sampling was used. Measured variables were maternal age, parity, gestational age, indica- tion for labor induction, cervical favorability, time of induction, quality of uterine activity achieved, type of delivery, and time point during induction when the decision of cesarean section was made. The clinical practice guidelines of international organizations of the specialty and the new guides arising from the 2012 proposal of limiting the first cesarean section were used in order to define ad- herence to the recommendations for induction.

RESULTS

Of the 2402 births, 289 which met the inclusion criteria were selected. Cesarean section was performed in 48% of the women subjected to induction, 60.8% nulliparous and 32.1% multiparous. Of those with unfavorable cervix, 72.2% received oxytocin for cervical maturation. Of the women subjected to delivery induction, 108 (37%) underwent cesarean section due to a diagnosis of failed induction. This was considered inadequate in all of them, considering that the diagnosis was made before reaching a dilatation of 6 cm in 88 (81.5%), with intact membranes in 67 (62%), with no uterine activity in 42 (38.9%), with poor quality uterine activity in 23 (21.3%) and in 55 (61%) who did not have at least 24 hours of latent phase before undergoing cesarean section.

CONCLUSIONS

Failure to adhere to the recommendations for adequate induction was found, added to a mistaken diagnosis of failed induction.

Double- versus single-balloon catheters for labour induction and cervical ripening: a meta-analysis

Background

The induction of labour is an increasingly common procedure in the obstetrics field. Various methods have been used to induce labour, among which balloon catheters play an important role. Whether the specifically designed double-balloon catheter is better than the single-balloon device in terms of efficacy, efficiency, safety and patient satisfaction remains controversial. Identifying even small differences between these two devices could be useful to guide clinical practices, to further explore their mechanisms, and to promote a better understanding of the optimal methods for inducing labour.

Methods

Using the population, intervention, comparison, outcomes and study designs (PICOS) principle, we searched the PubMed, EMBASE, OVID, SCI, CENTRAL, ClinicalTrial.gov, and CDSR databases to identify relevant randomised controlled trials (RCTs) from inception through February 14, 2018. The primary outcome was the caesarean delivery rate, and the secondary outcomes focused on efficacy, efficiency, safety, and patient satisfaction. The relative risks or mean differences, including their 95% confidence intervals, were calculated using fixed-effects or random-effects models. All statistical analyses were completed with RevMan version 5.3.

Results

From a total of 1326 articles, 7 RCTs involving 1159 women were included. There were no significant differences in primary outcomes (RR, 0.88 [0.65, 1.2]; p-value, 0.43) or secondary outcomes identified between single- and double-balloon catheters. However, heterogeneity existed for some aspects.

Conclusion

Both kinds of balloon catheter have similar levels of efficacy, efficiency, safety and patient satisfaction; however, the single-balloon method is considered to be more cost-effective.

Induction of labour with sequential double-balloon catheter and oral misoprostol versus oral misoprostol alone in obese women

Objective

To evaluate the efficacy of induction of labour in obese women using sequential double-balloon catheter and oral misoprostol in comparison with oral misoprostol alone.

Study design

In this cohort study, 400 pregnant women with BMI higher than 35 kg/m2 undergoing labour induction at term were included. Induction of labour with a double-balloon catheter and, if necessary, sequential oral misoprostol (n = 216) was compared to oral misoprostol alone (n = 184). The primary outcome measure was the caesarean section rate. Secondary outcome parameters were, among others, the induction-to-delivery-interval, the rate of vaginal delivery within 24 and 48 h as well as fetal outcome parameters.

Results

The caesarean section rate was significantly lower in the group with sequential use of double-balloon catheter and oral misoprostol (27.6% versus 37.5%, p = 0.0345). After stratification for parity this reduction was seen especially in nulliparous (38.6% versus 56.9%, p = 0.0039). The rate of abnormal CTG was significantly lower as well (19.9% versus 30.4%, p = 0.0150), particularly in nulliparous (25.9% versus 40.4%, p = 0.0138). Uni- and multivariable analyzes showed that the caesarean section rate was significantly influenced by the method of induction of labour (p = 0.0026), parity (p < 0.0001) and Bishop score (p = 0.0425).

Conclusion

In obese women, induction of labour with sequential use of double-balloon catheter and oral misoprostol is associated with significantly more normal vaginal deliveries and less caesarean sections.

Double-balloon catheter for induction of labor in 362 women with and without prior cesarean section

Objective

Balloon catheter is the preferred method for induction of labor in women with prior cesarean section. We sought to evaluate the rate of vaginal delivery, induction-delivery time and outcome predictors after induction with double-balloon catheter.

Study design

We conducted a retrospective cohort study including women with prior cesarean section undergoing induction of labor with a double-balloon catheter during the period January 2007–June 2014 at a large, tertiary Danish university hospital. For comparison, we included women with no prior cesarean section undergoing induction with double-balloon catheter after failed medical induction. Inclusion criteria were singleton pregnancy, an unfavorable cervix, intact membranes, cephalic presentation and either previous cesarean section or failed medical induction of labor. Exclusion criteria included contraindications for vaginal delivery, severe fetal malformation and stillbirth. Study subjects were identified in a local computerized system and data extracted from the medical records.

Results

Women with prior cesarean section (n = 304) induced with double-balloon catheter had a vaginal delivery rate of 50.3% (95% CI 44.7–55.9) compared to 51.7% (95% CI 39.2–64.1) in women with no prior cesarean section but preceding failed medical induction of labor (n = 58) (p = 0.85). BMI≥30 was associated with increased frequency of cesarean section. Median time from induction to vaginal delivery was 27.1(20.4–31.1) hours and 28.4(25.5–36.1) hours, respectively (p = 0.05). The rate of complete uterine rupture was 1.0%.

Conclusions

Similar success rates of approximately 50% for vaginal delivery were observed after induction of labor with a double-balloon catheter in women with and without prior caesarean section. A BMI ≥ 30 was associated with an increased frequency of caesarean section.

Foley catheter vs. oral misoprostol to induce labour among hypertensive women in India: a cost-consequence analysis alongside a clinical trial

OBJECTIVE

To determine the effectiveness and economic impact of two methods for induction of labour in hypertensive women, in low-resource settings.

DESIGN

Cost-consequence analysis of a previously reported multicentre, parallel, open-label randomised trial.

SETTING & POPULATION

A total of 602 women with a live fetus, aged ≥18 years requiring delivery for pre-eclampsia or hypertension, in two public hospitals in Nagpur, India.

METHODS

We performed a formal economic evaluation alongside the INFORM clinical trial. Women were randomised to receive transcervical Foley catheterisation or oral misoprostol 25 mcg. Healthcare expenditure was calculated using a provider-side microcosting approach.

MAIN OUTCOME MEASURES

Rates of vaginal this delivery within 24 hours of induction, healthcare expenditure per completed treatment episode.

RESULTS

Induction with oral misoprostol resulted in a (mean difference) $20.6USD reduction in healthcare expenditure [95% CI (-) $123.59 (-) $72.49], and improved achievement of vaginal delivery within 24 hours of induction, mean difference 10% [95% CI (-2 to 17.9%), P = 0.016]. Oxytocin administration time was reduced by 135.3 minutes [95% CI (84.4-186.2 minutes), P < 0.01] and caesarean sections by 9.1% [95% CI (1.1-17%), P = 0.025] for those receiving oral misoprostol. Following probabilistic sensitivity analysis, oral misoprostol was cost-saving in 63% of 5,000 bootstrap replications and achieved superior rates of vaginal delivery, delivery within 24 hours of induction and vaginal delivery within 24 hours of induction in 98.7%, 90.7%, and 99.4% of bootstrap simulations. Based on univariate threshold analysis, the unit price of oral misoprostol 25 mcg could feasibly increase 31-fold from $0.24 to $7.50 per 25 mcg tablet and remain cost-saving.

CONCLUSION

Compared to Foley catheterisation for the induction of high-risk hypertensive women, oral misoprostol improves rates of vaginal delivery within 24 hours of induction and may also reduce costs. Additional research performed in other low-resource settings is required to determine their relative cost-effectiveness.

TWEETABLE ABSTRACT

Oral misoprostol less costly and more effective than Foley catheter for labour induction in hypertension.

Patient satisfaction with the cervical ripening balloon as a method for induction of labour: a randomised controlled trial

INTRODUCTION

Evidence has shown that balloon catheters are as effective as prostaglandins (PGE) in achieving vaginal delivery within 24 hours of the start of induction of labour (IOL), with lower rates of uterine hyperstimulation, and similar Caesarean section and infection rates. International guidelines recommend mechanical methods as a method of IOL. We designed a prospective randomised controlled study to evaluate patient acceptance of the cervical ripening balloon (CRB) for IOL.

METHODS

Suitable women with a singleton term pregnancy without major fetal anomaly suitable for vaginal delivery were recruited and randomised to receive the CRB or PGE on the day of IOL. Characteristics of the women, labour and birth outcomes were obtained from case notes. Pain and satisfaction scores were obtained by interviewing the women at IOL and after delivery. The main outcome measures were participant characteristics, labour and birth outcomes, pain score, satisfaction scores, and whether the participant would recommend the mode of IOL.

RESULTS

There was no difference in the pain score between the two groups at the start of IOL, but thereafter, pain scores were lower in the CRB group compared to the PGE group (4.5 ± 2.3 vs. 5.6 ± 2.4, p = 0.044). Women were equally satisfied with both methods and equally likely to recommend their method for IOL.

CONCLUSION

Patient experience of IOL with CRB or PGE was equally satisfactory, although pain during induction was lower in the CRB group. We found that both methods of IOL are acceptable to women and should be made available to provide more options.

Comparison of vaginal misoprostol, laminaria, and isosorbide dinitrate on cervical preparation and labor duration of term parturient: a randomized double-blind clinical trial

Background

Cervical ripening plays an important role in successful labor induction.

Objective

This study aimed to compare the effects of misoprostol, laminaria tent, and isosorbide dinitrate (ISDN) on cervical ripening.

Methods

This double-blind three-armed clinical trial was conducted at Shahidan Mombini Teaching Hospital in Sabzevar, Iran, in 2016 on 96 singleton term pregnant women. Participants were randomly allocated to receive either two 20-mg ISDN tablets vaginally every 4 hours for a maximum of three doses or 25 mcg misoprostol vaginally every 6 hours for a maximum of two doses or laminaria tent for a maximum of 12 hours. The method of randomization was covariate adaptive randomization and the primary outcome measures were Bishop Score changes and labor duration. SPSS software version 18 was used for statistical analyses. Kruskal-Wallis, chi-square and ANOVA tests were applied for data analyses.

Results

Bishop Score changes were higher in the misoprostol group than in the two other groups (p=0.014). Time from start of medication to active phase of labor and delivery were 6.22±3.11 and 11.78±5.3 minutes in the misoprostol group, 11.25±3.07 and 17.62±4.07 minutes in the laminaria group, and 10.12±3.48 and 17.37±4.79 minutes in the ISDN group respectively (p<0.001). Cesarean rate was higher in the misoprostol group than the two other groups (p=0.016). No significant differences were observed between the study groups in terms of Apgar score and meconium-stained amniotic fluid.

Conclusions

Use of misoprostol results in more improvement of Bishop Score and reduced length of labor phases in comparison to laminaria tent and ISDN.

Trial registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct ID: IRCT2016050527643N2 in the Iranian Registry of Clinical Trials IRCT2015040921670N1.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Robson 10-groups classification system to access C-section in two public hospitals of the Federal District/Brazil

BACKGROUND

The global increase in C-section rates is real. In Brazil, these indices correspond to 58.94% in the Midwest region and 52.77% in the Federal District.

OBJECTIVE

To evaluate the C-section rates and identify the groups with the greatest risk at two reference hospitals in the public network of Federal District/Brazil, using 10-Group Robson System.

METHOD

A cross-sectional study of 6579 births assisted at the Hospital A (HA) and the Hospital B (HB) during 2013. The C-section rates in each group and its respective contribution to the total hospital C-sections was compared between HA and HB. To this, was used the proportion difference test (similar to chi-square test), with RR and 95% CI, and the logistic regression analysis (OR; 95% CI) among the groups with higher C-section/total C-section. The significance limit of p < 0.05 was defined for all tests.

RESULTS

The C-section rates were 50.8% at the HA and 42.3% at the HB, with 1.20 RR (95%CI = 1.13-1.28) at the HA. The highest rates were observed in Robson groups G5, G1, and G2. At the HA, G1 had a 21.5% C-section rate, which was greater than at the HB (13.8%; p < 0.05); the cesarean rates for groups G2 and G5 were higher at the HB (respectively, 18.6 and 38.1%) than at the HA (14.8 and 32.5%, respectively; p < 0.05).

CONCLUSION

These results point out specific goals to be achieved in order to reduce abusive cesarean rates in both A and B hospitals, especially in the primigravida and in those with previous C-section.

Single versus double-balloon catheters for the induction of labor of singleton pregnancies: a meta-analysis of randomized and quasi-randomized controlled trials

OBJECTIVE

To compare the efficacy of single- versus double-balloon catheter (SBC vs. DBC) for cervical ripening and labor induction with an unfavorable cervix.

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs) or quasi-RCTs (qRCT) regarding the use of SBC or DBC for labor induction of live singleton cephalic pregnancies (≥ 35 weeks) of any parity with an unripe cervix (Bishop score ≤ 6). Nine research databases were searched for original articles published in all languages up to November 2017 comparing both devices for labor induction. Five RCTs and one qRCT were included. Primary outcome measures were time from intervention (device placement) to birth time, vaginal delivery and cesarean section rates, and maternal satisfaction with the procedure. Risk of bias was evaluated with the Cochrane tool. Random effects models were used to combine data for meta-analyses. Summary measures were reported as mean differences and risk ratios (RR) with 95% confidence intervals.

RESULTS

Regardless of parity, pooled analyses of the six trials (n = 1060 women) found that mean intervention to birth time, vaginal delivery and cesarean section rates, and maternal satisfaction to the procedure were similar for both studied groups (SBC vs. DBC).

CONCLUSION

Measured primary outcome measures were similar regardless of the type of device used for labor induction of singleton pregnancies.

Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour.

OBJECTIVE

To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups.

METHODS

We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group's Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012-13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves.

RESULTS

We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 µg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed 'best'. Few studies collected information on women's views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective.

LIMITATIONS

There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses.

CONCLUSIONS

Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention.

FUTURE WORK

Future trials should be powered to detect a method that is more cost-effective than misoprostol solution and report outcomes included in this NMA.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005116.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Application effect of single balloon catheters in labor induction of pregnant women in late-term pregnancy and their influences on stress and inflammatory responses

This study was designed to evaluate the application effect of single balloon catheters and dinoprostone on promoting cervical ripening of pregnant women in late-term pregnancy and their influences on stress and inflammatory responses. A total of 160 pregnant women with indications of labor induction were included and randomly divided into the control (n=80) and observation (n=80) groups. Patients in the control group received labor induction by administration of dinoprostone at the vaginal vault, while those in the observation group received labor induction by domestic single balloon catheters. Cervical ripening (Bishop score), means of pregnancy, the total stage of labor, maternal and child complications, and Apgar scores of newborn infants at 1 min after delivery between the two groups were compared. At the prenatal and postpartum 12, 24 and 48 h, the levels of cortisol (COR), norepinephrine (NE) and β-endorphin (β-EP), were detected using radioimmunoassay, and those of C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α), were measured using enzyme-linked immunosorbent assay (ELISA). Cervical Bishop scores in the two groups after intervention were significantly higher than those before intervention, and the score of the observation group was significantly higher than that of the control group. The difference was statistically significant (P<0.05). In the observation group, the total stage of labor was significantly shortened, the Apgar score of the newborn infant at 1 min after delivery was increased compared with those in the control group, and the differences were statistically significant (P<0.05). The delivery rate of cesarean section in the observation group was lower than that in the control group, the overall incidence rate of perinatal complications was decreased, and the differences were statistically significant (P<0.05). The levels of stress and inflammatory response markers at 12 h after delivery in the two groups reached the peak, and then declined (P<0.05). The levels of stress and inflammatory response markers at each time-point after delivery in the observation group were significantly lower than those in the control group, and the difference was statistically significant (P<0.05). The results showed that the single balloon catheter promotes cervical ripening, improves pregnancy outcomes and reduces the stress and inflammatory responses of pregnant women in late-term pregnancy, and is better than dinoprostone and has better application and promotion values.

Hygroscopic dilators vs balloon catheter ripening of the cervix for induction of labor in nulliparous women at term: Retrospective study

Objective

To compare the efficacy and safety of hygroscopic dilators and balloon catheters for ripening of the cervix in induction of labor.

Study design

This retrospective, observational study used data from the Successive Pregnancy Birth Registry System of the Japan Society of Obstetrics and Gynecology from 2012 to 2014. Nulliparous women in whom labor was induced by mechanical methods of cervical ripening at term were enrolled. The eligible women were divided into dilator, balloon <40 mL, balloon ≧40 mL, and overlapping groups.

Results

The groups included 4645, 4100, 6615, and 1992 women, respectively. In the overlapping group, which included the women in whom delivery was most difficult, the vaginal delivery rate was lower and the intrauterine infection and neonatal mortality rates were higher than those in the dilator group. No difference in the vaginal delivery rate was observed among the dilator, balloon <40 mL, and balloon ≧40 mL groups (74.6%, 72.3%, and 73.8%, respectively; p>0.05). The vaginal instrumental delivery rate was higher in the two-balloon groups than in the dilator group. The volume of intrapartum hemorrhage was lowest in the dilator group. No significant difference in the frequencies of uterine rupture and intrauterine infection were observed among the dilator and two-balloon groups. With regard to neonatal outcomes, the frequency of a low Apgar score was statistically significantly lower in the dilator group than in the two-balloon groups. Moreover, the frequency of neonatal death tended to be lower in the dilator group than in the two-balloon groups.

Conclusion

With regard to cervical ripening for labor induction in nulliparous women at term, the vaginal delivery rate on using a dilator and on using a balloon seems to be equivalent. Concerning maternal complications and neonatal outcomes, cervical ripening with hygroscopic dilators in labor induction might be safer.

Racial and Ethnic Differences in Utilization of Labor Management Strategies Intended to Reduce Cesarean Delivery Rates

OBJECTIVE

To examine whether racial and ethnic differences exist in the frequency of and indications for cesarean delivery and to assess whether application of labor management strategies intended to reduce cesarean delivery rates is associated with patient's race and ethnicity.

METHODS

This is a secondary analysis of a multicenter observational obstetric cohort. Trained research personnel abstracted maternal and neonatal records of greater than 115,000 pregnant women from 25 hospitals (2008-2011). Women at term with singleton, nonanomalous, vertex, liveborn neonates were included in two cohorts: 1) nulliparous women (n=35,529); and 2) multiparous women with prior vaginal deliveries only (n=39,871). Women were grouped as non-Hispanic black, non-Hispanic white, Hispanic, and Asian. Multivariable logistic regression was used to evaluate the following outcomes: overall cesarean delivery frequency, indications for cesarean delivery, and utilization of labor management strategies intended to safely reduce cesarean delivery.

RESULTS

A total of 75,400 women were eligible for inclusion, of whom 47% (n=35,529) were in the nulliparous cohort and 53% (n=39,871) were in the multiparous cohort. The frequencies of cesarean delivery were 25.8% among nulliparous women and 6.0% among multiparous women. For nulliparous women, the unadjusted cesarean delivery frequencies were 25.0%, 28.3%, 28.7%, and 24.0% for non-Hispanic white, non-Hispanic black, Asian, and Hispanic women, respectively. Among nulliparous women, the adjusted odds of cesarean delivery were higher in all racial and ethnic groups compared with non-Hispanic white women (non-Hispanic black adjusted odds ratio [OR] 1.47, 95% CI 1.36-1.59; Asian adjusted OR 1.26, 95% CI 1.14-1.40; Hispanic adjusted OR 1.17, 95% CI 1.07-1.27) as a result of greater odds of cesarean delivery both for nonreassuring fetal status and labor dystocia. Nonapplication of labor management strategies regarding failed induction, arrest of dilation, arrest of descent, or cervical ripening did not contribute to increased odds of cesarean delivery for non-Hispanic black and Hispanic women. Compared with non-Hispanic white women, Hispanic women were actually less likely to experience elective cesarean delivery (adjusted OR 0.60, 95% CI 0.42-0.87) or cesarean delivery for arrest of dilation before 4 hours (adjusted OR 0.67, 95% CI 0.49-0.92). Additionally, compared with non-Hispanic white women, Asian women were more likely to experience cesarean delivery for nonreassuring fetal status (adjusted OR 1.29, 95% CI 1.09-1.53) and to have had that cesarean delivery be performed in the setting of a 1-minute Apgar score 7 or greater (adjusted OR 1.79, 95% CI 1.07-3.00). A similar trend was seen among multiparous women with prior vaginal deliveries.

CONCLUSION

Although racial and ethnic disparities exist in the frequency of cesarean delivery, differential use of labor management strategies intended to reduce the cesarean delivery rate does not appear to be associated with these racial and ethnic disparities.

Effect of Premature Rupture of Membranes on Induction of Labor: A Historical Cohort Study

Objective

The aim of this study was to assess the influence of premature rupture of membranes (PROM) on the induction of labor.

Material and Method

This historical cohort study analyzed 1861 inductions of labor at term using misoprostol which occurred between 2010 and 2015. Exclusion criteria included intrauterine fetal death, previous cesarean section, and fetal structural or chromosomal anomalies. Induction of labor for PROM (PROM group) was compared to induction for other indications (no-PROM group); the primary outcome measure was the cesarean section rate.

Results

The cesarean section rate for the PROM group was significantly lower (21.9% vs. 26.3%, p = 0.029). The induction-to-delivery interval was shorter (mean: 972 [854 – 6734] min vs. 1741 [97 – 10 834] min, p < 0.0001) and the rates of vaginal birth within 24 hours (80.9 vs. 52.0%, p = 0.0001) and 48 hours (98.4 vs. 85.3%, p = 0.0001) were higher in the PROM group. The impact of PROM on the cesarean section rate was not significant in multivariate analysis; however, PROM was found to have the greatest effect on the induction-to-delivery interval (p < 0.0001).

Conclusion

Premature rupture of membranes significantly affects various outcome measures when delivery is induced, particularly the induction-to-delivery interval.

Sequential Versus Concurrent Use of Vaginal Misoprostol Plus Foley Catheter for Induction of Labor: A Randomized Clinical Trial

Background

To compare between the sequential and concurrent use of vaginal misoprostol plus Foley catheter for labor induction.

Methods

This single-center, non-blinded randomized study was conducted at the department of Obstetrics and Gynecology, Faculty of medicine, Zagazig University. A total of 160 women with full term singleton pregnancy, cephalic presentation and bishop score ≤ 6 were randomized for labor induction with either concurrent or sequential use of vaginal misoprostol plus Foley catheter (80 cases in each group). The primary outcome measured was induction-to-delivery interval and secondary outcomes mesaured were vaginal delivery within 24 h, number of doses needed to induce labor, need of oxytocin for augmentation of labor, cesarean section rate, maternal or neonatal complications.

Results

The mean induction-to-delivery interval was 22.33 ± 13.28 h versus 18.45 ± 14.34 h (p = 0.041) in sequential and concurrent group, respectively. The percentage of women who completed vaginal delivery within 24 h was 51% versus 61% (p = 0.046) in sequential and concurrent group, respectively. Other maternal and neonatal outcomes were similar in both groups.

Conclusion

Concurrent use of vaginal misoprostol plus Foley catheter for labor induction was associated with shorter induction-to delivery interval compared to sequential use, and it increases the rate of vaginal delivery in the first 24 h.

Time-to-delivery and delivery outcomes comparing three methods of labor induction in 7551 nulliparous women: a population-based cohort study

OBJECTIVE

Determine time-to-delivery and mode-of-delivery in labor induction among women with unripe cervix.

STUDY DESIGN

7551 nulliparous women with singleton deliveries, ⩾37 weeks, Bishop Score ⩽6, induced with dinoprostone, misoprostol or transcervical single balloon catheter. Linear regression analysis was used to estimate mean time-to-delivery with β-estimates and 95% confidence intervals with adjustments. Multivariable logistic regression analysis was used to calculate odds of cesarean delivery, instrumental vaginal delivery, maternal and neonatal outcomes.

RESULTS

Adjusted mean time-to-delivery was 6.9 and 1.5 h shorter, respectively, when inducing labor with balloon catheter (mean 18.3 h, β -6.9, 95% confidence intervals; -7.6 to -6.3) or misoprostol (mean 23.7 h, β -1.5, 95% confidence intervals; -2.3 to -0.8) compared with dinoprostone (mean 25.2 h). There were no significant differences in adverse maternal or infant outcomes between induction methods.

CONCLUSIONS

Balloon catheter is the most effective induction method with respect to time-to-delivery in nulliparous women at term compared with prostaglandin methods.

Acupuncture or acupressure for induction of labour

BACKGROUND

This is one of a series of reviews of methods of cervical ripening and labour induction. The use of complementary therapies is increasing. Women may look to complementary therapies during pregnancy and childbirth to be used alongside conventional medical practice. Acupuncture involves the insertion of very fine needles into specific points of the body. Acupressure is using the thumbs or fingers to apply pressure to specific points. The limited observational studies to date suggest acupuncture for induction of labour has no known adverse effects to the fetus, and may be effective. However, the evidence regarding the clinical effectiveness of this technique is limited.

OBJECTIVES

To determine, from the best available evidence, the effectiveness and safety of acupuncture and acupressure for third trimester cervical ripening or induction of labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2016), PubMed (1966 to 25 November 2016), ProQuest Dissertations & Theses (25 November 2016), CINAHL (25 November 2016), Embase (25 November 2016), the WHO International Clinical Trials Registry Portal (ICTRP) (3 October 2016), and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised controlled trials comparing acupuncture or acupressure, used for third trimester cervical ripening or labour induction, with placebo/no treatment or other methods on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. The quality of the evidence was assessed using GRADE.

MAIN RESULTS

This updated review includes 22 trials, reporting on 3456 women. The trials using manual or electro-acupuncture were compared with usual care (eight trials, 760 women), sweeping of membranes (one trial, 207 women), or sham controls (seven trials, 729 women). Trials using acupressure were compared with usual care (two trials, 151 women) or sham controls (two trials, 239 women). Many studies had a moderate risk of bias.Overall, few trials reported on primary outcomes. No trial reported vaginal delivery not achieved within 24 hours and uterine hyperstimulation with fetal heart rate (FHR) changes. Serious maternal and neonatal death or morbidity were only reported under acupuncture versus sham control. Acupuncture versus sham control There was no clear difference in caesarean sections between groups (average risk ratio (RR) 0.80, 95% confidence interval (CI) 0.56 to 1.15, eight trials, 789 women; high-quality evidence). There were no reports of maternal death or perinatal death in the one trial that reported this outcome. There was evidence of a benefit from acupuncture in improving cervical readiness for labour (mean difference (MD) 0.40, 95% CI 0.11 to 0.69, one trial, 125 women), as measured by cervical maturity within 24 hours using Bishop's score. There was no evidence of a difference between groups for oxytocin augmentation, epidural analgesia, instrumental vaginal birth, meconium-stained liquor, Apgar score < 7 at five minutes, neonatal intensive care admission, maternal infection, postpartum bleeding greater than 500 mL, time from the trial to time of birth, use of induction methods, length of labour, and spontaneous vaginal birth. Acupuncture versus usual care There was no clear difference in caesarean sections between groups (average RR 0.77, 95% CI 0.51 to 1.17, eight trials, 760 women; low-quality evidence). There was an increase in cervical maturation for the acupuncture (electro) group compared with control (MD 1.30, 95% CI 0.11 to 2.49, one trial, 67 women) and a shorter length of labour (minutes) in the usual care group compared to electro-acupuncture (MD 124.00, 95% CI 37.39 to 210.61, one trial, 67 women).There appeared be a differential effect according to type of acupuncture based on subgroup analysis. Electro-acupuncture appeared to have more of an effect than manual acupuncture for the outcomes caesarean section (CS), and instrumental vaginal and spontaneous vaginal birth. It decreased the rate of CS (average RR 0.54, 95% CI 0.37 to 0.80, 3 trials, 327 women), increased the rate of instrumental vaginal birth (average RR 2.30, 95%CI 1.15 to 4.60, two trials, 271 women), and increased the rate of spontaneous vaginal birth (average RR 2.06, 95% CI 1.20 to 3.56, one trial, 72 women). However, subgroup analyses are observational in nature and so results should be interpreted with caution.There were no clear differences between groups for other outcomes: oxytocin augmentation, use of epidural analgesia, Apgar score < 7 at 5 minutes, neonatal intensive care admission, maternal infection, perineal tear, fetal infection, maternal satisfaction, use of other induction methods, and postpartum bleeding greater than 500 mL. Acupuncture versus sweeping if fetal membranes One trial of acupuncture versus sweeping of fetal membranes showed no clear differences between groups in caesarean sections (RR 0.64, 95% CI 0.34 to 1.22, one trial, 207 women, moderate-quality evidence), need for augmentation, epidural analgesia, instrumental vaginal birth, Apgar score < 7 at 5 minutes, neonatal intensive care admission, and postpartum bleeding greater than 500 mL. Acupressure versus sham control There was no evidence of benefit from acupressure in reducing caesarean sections compared to control (RR, 0.94, 95% CI 0.68 to 1.30, two trials, 239 women, moderate-quality evidence). There was no evidence of a clear benefit in reduced oxytocin augmentation, instrumental vaginal birth, meconium-stained liquor, time from trial intervention to birth of the baby, and spontaneous vaginal birth. Acupressure versus usual care There was no evidence of benefit from acupressure in reducing caesarean sections compared to usual care (RR 1.02, 95% CI 0.68 to 1.53, two trials, 151 women, moderate-quality evidence). There was no evidence of a clear benefit in reduced epidural analgesia, Apgar score < 7 at 5 minutes, admission to neonatal intensive care, time from trial intervention to birth of the baby, use of other induction methods, and spontaneous vaginal birth.

AUTHORS' CONCLUSIONS

Overall, there was no clear benefit from acupuncture or acupressure in reducing caesarean section rate. The quality of the evidence varied between low to high. Few trials reported on neonatal morbidity or maternal mortality outcomes. Acupuncture showed some benefit in improving cervical maturity, however, more well-designed trials are needed. Future trials could include clinically relevant safety outcomes.

Mechanical cervicAl ripeninG for women with PrOlongedPregnancies (MAGPOP): protocol for a randomised controlled trial of a silicone double balloon catheter versus the Propess system for the slow release of dinoprostone for cervical ripening of prolonged pregnancies

INTRODUCTION

Induction of labour for prolonged pregnancies (PP) when the cervix is unfavourable is a challenging situation. Cervical ripening by pharmacological or mechanical techniques before oxytocin administration is used to increase the likelihood of vaginal delivery. Both techniques are equally effective in achieving vaginal delivery but excessive uterine activity, which induces fetal heart rate (FHR) anomalies, is more frequent after the pharmacological intervention. We hypothesised that mechanical cervical ripening could reduce the caesarean rate for non-reassuring FHR especially in PP where fetuses are already susceptible to this.

METHODS AND ANALYSIS

A multicentre, superiority, open-label, parallel-group, randomised controlled trial that aims to compare cervical ripening with a mechanical device (Cervical Ripening Balloon, Cook-Medical Europe, Ireland) inserted in standardised manner for 24 hours to pharmacological cervical ripening (Propess system for slow release system of 10 mg of dinoprostone, Ferring SAS, France) before oxytocin administration. Women (n=1220) will be randomised in a 1:1 ratio in 15 French units. Participants will be women with a singleton pregnancy, a vertex presentation, a term ≥41+0 and≤42+0 week's gestation, and for whom induction of labour is planned. Women with a Bishop score ≥6, a prior caesarean delivery, premature rupture of membranes or with any contraindication for vaginal delivery will be excluded. The primary endpoint is the caesarean rate for non-reassuring FHR. Secondary outcomes are related to delivery and perinatal morbidity. As study investigators and patients cannot be masked to treatment assignment, to compensate for the absence of blinding, an independent endpoint adjudication committee, blinded to group allocation, will determine whether the caesarean for non-reassuring FHR was justified.

ETHICS AND DISSEMINATION

Written informed consent will be obtained from all participants. The Tours Research ethics committee has approved this study (2016-R23, 29 November 2016). Study findings will be submitted for publication and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

NCT02907060; pre-results.

Foley catheterisation versus oral misoprostol for induction of labour in hypertensive women in India (INFORM): a multicentre, open-label, randomised controlled trial

BACKGROUND

Between 62 000 and 77 000 women die annually from pre-eclampsia and eclampsia. Prompt delivery, preferably by the vaginal route, is vital for good maternal and neonatal outcomes. Two low-cost interventions-low-dose oral misoprostol tablets and transcervical Foley catheterisation-are already used in low-resource settings. We aimed to compare the relative risks and benefits of these interventions.

METHODS

We undertook this multicentre, open-label, randomised controlled trial in two public hospitals in Nagpur, India. Women (aged ≥18 years) who were at 20 weeks' gestation or later with a live fetus and required delivery as a result of pre-eclampsia or hypertension were randomly assigned (1:1), via computer-generated block randomisation (block sizes of four, six, and eight) with concealment by use of opaque, sequentially numbered, sealed envelopes, to receive labour induction with either oral misoprostol 25 μg every 2 h (maximum of 12 doses) or a transcervical Foley catheter (silicone, size 18 F with 30 mL balloon). Randomisation was stratified by study centre. The catheter remained in place until active labour started, the catheter fell out, or 12 h had elapsed. If the catheter did not fall out within 12 h, induction continued with artificial membrane rupture and oxytocin, administered through a micro-drip gravity infusion set. Fetal monitoring was by intermittent auscultation. The primary outcome was vaginal birth within 24 h. Due to the nature of the interventions, masking of participants, study investigators, and care providers to group allocation was not possible. We analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01801410.

FINDINGS

Between Dec 20, 2013, and June 29, 2015, we randomly assigned 602 women to induction with misoprostol (n=302) or the Foley catheter (n=300; intention-to-treat population). Vaginal birth within 24 h was more common in women in the misoprostol group than in the Foley catheter group (172 [57·0%] vs 141 [47·0%] women; absolute risk difference 10·0%, 95% CI 2·0-17·9; p=0·0136). Rates of uterine hyperstimulation were low in both the misoprostol and Foley catheter groups (two [0·7%] vs one [0·3%] cases; absolute risk difference 0·3%, 95% CI -0·8 to 1·5; p=0·566) and neonatal deaths did not differ significantly between groups (six [2·0%] vs three [1·0%] neonatal deaths; 1·0, -1·04 to 2·97; p=0·322). 17 serious adverse events (3%) were reported during the study: one case of intrapartum convulsion and one case of disseminated intravascular coagulation (both in the Foley group); ten perinatal deaths, including two stillbirths (both in the Foley catheter group) and eight neonatal deaths (n=5 in the misoprostol group and n=3 in the Foley catheter group); and five of neonatal morbidity, comprising birth asphyxia (n=3), septicaemia (n=1), and neonatal convulsion (n=1).

INTERPRETATION

Oral misoprostol was more effective than transcervical Foley catheterisation for induction of labour in women with pre-eclampsia or hypertension. Future studies are required to assess whether oxytocin augmentation following misoprostol can be replaced by regular doses of oral misoprostol tablets.

FUNDING

Medical Research Council, Department for International Development, and Wellcome Trust Joint Global Health Trials Scheme.

Foley catheter for cervical priming in induction of labour at University Obstetrics Unit, Colombo, Sri Lanka: a clinical audit with a patient satisfaction survey

BACKGROUND

Intracervical insertion of a Foley catheter (FC) has shown to be a safe, effective and relatively feasible mechanical method of cervical priming in induction of labour (IOL). We evaluated indications, effectiveness, patient acceptability and outcomes of FC use in IOL adhering to the ward protocol in our unit.

METHODS

A clinical audit with a patient satisfaction survey conducted between July and September 2013 in University Obstetric Unit, Colombo, Sri Lanka. Patients selected for IOL for obstetric reasons were primed with Foley as per ward protocol. All had singleton pregnancies with cephalic presentation, intact membranes and period of gestation of 37 weeks or above. Women with a history of more than one caesarean section or uterine surgery, low-lying placenta and fetal growth restriction were excluded. Subjects who had a Modified Bishop Score (MBS) of less than 3, a 16Fr FC was inserted into cervical canal. Catheter was left undisturbed until spontaneous expulsion or no longer than 48 h. In women with MBS of less than 6 at 48 h after FC insertion, 3 mg prostaglandin E2 vaginal tablet was used subsequently. Artificial membrane rupture with or without oxytocin was used if MBS of 6 or more and in women not in labour 24 h after prostaglandins. Patient satisfaction for Foley insertion was assessed with regards to the degree of comfort using a validated visual analogue scale (0-10).

RESULTS

There were a total of 910 deliveries during the study period. Fifty-six women were primed with FC. Thirty-two (57%) were nulliparous. During induction of labour, 53(95%) reported mild or no discomfort. MBS of 6 or more was achieved in 36/56 (64%) Foley insertions. Twenty needed further intervention with prostaglandins. FC only group had 5 caesarean sections and 31 vaginal deliveries and Foley/prostaglandin group had 7 caesarean sections and 13 vaginal deliveries. Of the 24 women who were induced due to completion of 41 weeks of gestation with otherwise uncomplicated pregnancies, 17 had MBS >6 post priming with Foley and 20 (83%) delivered vaginally. Subjects who had Foley only had a lesser chance of having a caesarean delivery compared to subjects who had Foley followed by prostaglandin (relative risk = 0.40, 95% CI = 0.15-1.09, P = 0.09).

DISCUSSION

FC is a good choice for pre-induction cervical priming with high patient comfort. FC becomes more important in IOL cost reduction in our setting. FC alone seems to be an effective for IOL in women who have completed 41 weeks of gestation with otherwise uncomplicated pregnancies.

Double-balloon catheter for induction of labour in women with a previous cesarean section, could it be the best choice?

Introduction

We analysed the efficacy and safety of double-balloon catheter for cervical ripening in women with a previous cesarean section and which were the most important variables associated with an increased risk of repeated cesarean delivery.

Materials and methods

We designed an observational retrospective study of 418 women with unfavourable cervices (Bishop Score <5), a prior cesarean delivery, and induction of labour with a double-balloon catheter. Baseline maternal data and perinatal outcomes were recorded for a descriptive, bivariate, and multivariate analysis. A p value <0.05 was considered statistically significant.

Results

Most women improved their initial Bishop Score (89.5%) although only a 20.8% of them went into spontaneous active labour. Finally, 51.4% of the women achieved a vaginal delivery. Five cases of intrapartum uterine rupture (1.2%) occurred. After multivariate analysis, main risk factors for repeated cesarean section were dystocia in the previous pregnancy (OR 1.744; CI 95% 1.066–2.846), the absence of previous vaginal delivery (OR 2.590; CI 95% 1.066–6.290), suspected fetal macrosomia (OR 2.410; CI 95% 0.959–6.054), and duration of oxytocin induction period (OR 1.005; CI 95% 1.004–1.006). The area under the curve was 0.789 (p < 0.001).

Conclusions

Double-balloon catheter seems to be safe and effective for cervical ripening in women with a previous cesarean delivery and unfavourable cervix. In our study, most women could have a vaginal delivery in spite of their risk factors for cesarean delivery. A multivariate model based on some clinical variables has moderate predictive value for intrapartum cesarean section.