Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term

Results of the RE-DINO multicenter randomized trial on the repeated use of vaginal dinoprostone (Propess®) for labor induction in patients at term

BACKGROUND

Labor is induced in over 25% of women in France. Prostaglandins, especially intravaginal dinoprostone (Propess®), are widely used to initiate cervical ripening. If labor does not start within 24 hours, there is uncertainty about whether to administer a second dinoprostone pessary or to use oxytocin to induce labor in order to achieve a vaginal delivery.

OBJECTIVES

Our principal objective was to determine whether placement of a second Propess®, followed by oxytocin (Syntocinon®) if necessary, in pregnant women for whom the first Propess® failed to induce cervical ripening increases the vaginal delivery rate compared to direct oxytocin injection. The vaginal delivery rate was therefore the primary outcome. The secondary outcomes were the cervical ripening failure rate and maternal and fetal morbidity and mortality.

STUDY DESIGN

RE-DINO is a prospective, open-label, multicenter, randomized superiority trial with two parallel arms running in 7 French hospitals. Patients at > 37 weeks of gestation who had unfavorable cervical conditions (Bishop score < 6) 24 hours after placement of the first Propess® (vaginal patch featuring progressive continuous diffusion of 10 mg dinoprostone), with fetuses in cephalic presentation, were included.

RESULTS

160 pregnant women were randomized, 80 patients in each group, from December 2016 through April 2022. Baseline characteristics such as age, BMI, maternal age at induction and Bishop score at induction were similar between both groups. Vaginal delivery occurred in 76.3% of cases in the 2nd Propessࣨ group and 73.8% of cases in the Syntocinon® group (RR = 1.03 [0.86; 1.24], p=0.715). Although the cesarean section rate was similar in each group, there were significantly more cesarean sections for arrest of dilatation (52.6% vs 19%; p=0.0262) in the Propess® group and a larger, borderline-significant difference in patients having operative vaginal delivery (24.6% vs 11.9%; p=0.07) for abnormal fetal heart rate (80% vs 29%; p=0.05). There was significantly more failure of cervical ripening in the Propessࣨ group (57.1% vs 19%; RR=2.59 ; 95% CI [1.64; 4.11]; p < 0.0001) and the interval between study treatment and delivery was also significantly longer (28.1h vs 9,7h; p<0.0001). There was a higher incidence of post-partum hemorrhage in the Propessࣨ group, although this was not significant (11.3% vs 5% ; p=0,15), but also more newborns with acidosis (39.3% vs 27.9% ; p=0.18) or severe acidosis (8,6% vs 3.4% ; p=0.27), more meconium fluid (11.3% vs 6.3% ; p =0.26) and transferred to intensive care (5% vs 2.5% ; p=0.68).

CONCLUSION

Our data showed no superiority of a second dinoprostone pessary over oxytocin in patients not responding to initial prostaglandins E2 maturation for labor induction. Repeated use of Propess® is not useful for induction of labor.

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.

Is there an interest in repeating the vaginal administration of dinoprostone (Propess®), to promote induction of labor of pregnant women at term? (RE-DINO): study protocol for a randomized controlled trial

BACKGROUND

Labor is induced in over 20% of women in France. Prostaglandins, especially intravaginal dinoprostone (Propess®), are widely used to initiate cervical ripening. If labor does not start within 24 h, there is uncertainty about whether to administer a second dinoprostone pessary or to use oxytocin to induce labor in order to achieve a vaginal delivery.

METHODS

RE-DINO is a prospective, open-label, multicenter, randomized superiority trial with two parallel arms running in six French hospitals. A total of 360 patients ≥ 18 years of age at > 37 weeks of gestation who exhibit unfavorable cervical conditions (Bishop score < 6) 24 h after placement of the first Propess®, with fetuses in cephalic presentation, will be included. Patients with premature membrane rupture, uterine scars, or multiple pregnancies will be excluded. Our principal objective is to determine whether placement of a second Propess® (followed by oxytocin [Syntocinon®], if necessary) in women for whom the first Propess® failed to induce cervical ripening increases the vaginal delivery rate compared to direct oxytocin injection. The vaginal delivery rate is therefore the primary outcome. The secondary outcomes are the induction failure rates and maternofetal morbidity and mortality.

DISCUSSION

This study may help in determining the optimal way to induce labor after failure of a first Propess®, an unresolved problem to date. This trial explores the effectiveness and safety of placing a second Propess® and may contribute to development of an obstetric consensus.

TRIAL REGISTRATION

Registered on 2 September 2016 at clinicaltrials.gov (identification number NCT02888041).

Prostaglandin dehydrogenase is a target for successful induction of cervical ripening

The cervix represents a formidable structural barrier for successful induction of labor. Approximately 10% of pregnancies undergo induction of cervical ripening and labor with prostaglandin (PG) E₂ or PGE analogs, often requiring many hours of hospitalization and monitoring. On the other hand, preterm cervical ripening in the second trimester predicts preterm birth. The regulatory mechanisms of this paradoxical function of the cervix are unknown. Here, we show that PGE₂ uses cell-specific EP2 receptor-mediated increases in Ca²⁺ to dephosphorylate and translocate histone deacetylase 4 (HDAC4) to the nucleus for repression of 15-hydroxy prostaglandin dehydrogenase (15-PGDH). The crucial role of 15-PGDH in cervical ripening was confirmed in vivo. Although PGE₂ or 15-PGDH inhibitor alone did not alter gestational length, treatment with 15-PGDH inhibitor + PGE₂ or metabolism-resistant dimethyl-PGE₂ resulted in preterm cervical ripening and delivery in mice. The ability of PGE₂ to selectively autoamplify its own synthesis in stromal cells by signaling transcriptional repression of 15-PGDH elucidates long sought-after molecular mechanisms that govern PG action in the cervix. This report details unique mechanisms of action in the cervix and serves as a catalyst for (i) the use of 15-PGDH inhibitors to initiate or amplify low-dose PGE₂-mediated cervical ripening or (ii) EP2 receptor antagonists, HDAC4 inhibitors, and 15-PGDH activators to prevent preterm cervical ripening and preterm birth.

Predicting factors for success of vaginal delivery in preterm induction with prostaglandin E2

Objective

To evaluate the efficacy and safety of prostaglandin (PG) E₂ for preterm labor induction and to investigate the predictive factors for the success of vaginal delivery.

Methods

A retrospective cohort study was performed in women (n=155) at 24+0 to 36+6 weeks of gestation who underwent induction of labor using a PGE₂ vaginal pessary (10 mg, Propess) from January 2009 to December 2015. Success rates of vaginal delivery according to gestational age at induction and incidence of intrapartum complications such as tachysystole and nonreassuring fetal heart rate were investigated. Multivariable logistic regression analysis was performed to evaluate the predictive factors for success of labor induction.

Results

The vaginal delivery rate was 57% (n=89) and the rate of cesarean delivery after induction was 43% (n=66). According to gestational age, labor induction was successful in 16.7%, 50.0%, and 62.8% of patients at 24 to 31, 32 to 33, and 34 to 36 weeks, showing a stepwise increase (P=0.006). There were 18 cases (11%) of fetal distress, 9 cases (5.8%) of tachysystole, and 6 cases (3.8%) of massive postpartum bleeding (>1,000 mL). After adjusting for confounding factors, multiparity (odds ratio [OR], 8.47; 95% confidence interval [CI], 3.10 to 23.14), younger maternal age (OR, 0.84; 95% CI, 0.75 to 0.94), advanced gestational age at induction (OR, 1.06; 95% CI, 1.02 to 1.09), rupture of membranes (OR, 11.83; 95% CI, 3.55 to 39.40), and the Bishop score change after removal of PGE₂ (OR, 2.19; 95% CI, 1.0 to 4.8) were significant predictors of successful preterm vaginal delivery.

Conclusion

An understanding of the principal predictive factors of successful preterm labor induction, as well as the safety of PGE₂, will provide useful information when clinicians consult with preterm pregnant women requiring premature delivery.

Isosorbide Mononitrate a Nitric Oxide Donor: A Study of Its Efficacy and Safety as an Agent for Cervical Ripening

OBJECTIVE

To study the efficacy and safety profile of isosorbide mononitrate (IMN) as an agent for cervical ripening.

METHODOLOGY

This study was conducted in the Department of Obstetrics and Gynecology, M Y Hospital & M G M Medical College Indore from September 2011 to February 2013. Pregnant women attending the antenatal clinics were screened for possible participation in the study after explaining the nature of the study. This study was conducted on 150 patients. An initial dose of 40 mg IMN was applied in the posterior vaginal fornix, and the same dose was repeated after 6 h. Cervical ripening was assessed by the change in Bishop Score 12 h after the initial application.

RESULTS

In a study of 150 cases, mean maternal age was 22.2 ± 2.6 years (range 19-35 years) and mean gestational age was 40.5 ± 1.07 (range 40-42 weeks). 52 women were primigravidas, while 98 were multigravidas. The mean Bishop Score-before drug administration was 1.94 ± 1.3 (range 0-5), and mean fetal heart rate was 137 ± 6.2 bpm. The mean of Bishop scores before IMN administration was 1.94 ± 1.3, while mean of Bishop score after drug administration was 6.7 ± 2.2; mean difference was equal to 4.76. P value was equal to 0.0001. By conventional criteria, this difference is considered to be statistically significant. The mode of delivery 96 (64 %) delivered vaginally, while 54 (36 %) were delivered by Cesarean section. Mean Apgar score at 1 min was 8.2 ± 0.9 SD (range 7-10), while mean Apgar score at 5 min was 9.4 ± 0.6 (range 8-10). The only side effect noted was headache, and 30 cases (20 %) complained of headache.

CONCLUSION

IMN seems to be effective, safe, inexpensive, and well-tolerated agent for cervical ripening. It is cost effective and safe with minimal side effects.

Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term

BACKGROUND

Prostaglandins have been used for induction of labour since the 1960s. This is one of a series of reviews evaluating methods of induction of labour. This review focuses on prostaglandins given per vaginam, evaluating these in comparison with placebo (or expectant management) and with each other; prostaglandins (PGE2 and PGF2a); different formulations (gels, tablets, pessaries) and doses.

OBJECTIVES

To determine the effects of vaginal prostaglandins E2 and F2a for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment or other vaginal prostaglandins (except misoprostol).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2014) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment, with each other, or other methods listed above it on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

We assessed studies and extracted data independently.

MAIN RESULTS

Seventy randomised controlled trials (RCTs) (11,487 women) are included. In this update seven new RCTs (778 women) have been added. Two of these new trials compare PGE2 with no treatment, four compare different PGE2 formulations (gels versus tablets, or sustained release pessaries) and one trial compares PGF2a with placebo. The majority of trials were at unclear risk of bias for most domains.Overall, vaginal prostaglandin E2 compared with placebo or no treatment probably reduces the likelihood of vaginal delivery not being achieved within 24 hours. The risk of uterine hyperstimulation with fetal heart rate changes is increased (4.8% versus 1.0%, risk ratio (RR) 3.16, 95% confidence interval (CI) 1.67 to 5.98, 15 trials, 1359 women). The caesarean section rate is probably reduced by about 10% (13.5% versus 14.8%, RR 0.91, 95% CI 0.81 to 1.02, 36 trials, 6599 women). The overall effect on improving maternal and fetal outcomes (across a variety of measures) is uncertain.PGE2 tablets, gels and pessaries (including sustained release preparations) appear to be as effective as each other, small differences are detected between some outcomes, but these maybe due to chance.

AUTHORS' CONCLUSIONS

Prostaglandins PGE2 probably increase the chance of vaginal delivery in 24 hours, they increase uterine hyperstimulation with fetal heart changes but do not effect or may reduce caesarean section rates. They increase the likelihood of cervical change, with no increase in operative delivery rates. PGE2 tablets, gels and pessaries appear to be as effective as each other, any differences between formulations are marginal but may be important.

Outpatient versus inpatient induction of labour for improving birth outcomes

BACKGROUND

More than 20% of women undergo induction of labour in some countries. The different methods used to induce labour have been the focus of previous reviews, but the setting in which induction takes place (hospital versus outpatient settings) may have implications for maternal satisfaction and costs. It is not known whether some methods of induction that are effective and safe in hospital are suitable in outpatient settings.

OBJECTIVES

To assess the effects on outcomes for mothers and babies of induction of labour for women managed as outpatients versus inpatients.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013).

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised trials in which inpatient and outpatient methods of cervical ripening or induction of labour have been compared.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial reports for inclusion. Two review authors carried out data extraction and assessment of risk of bias independently.

MAIN RESULTS

We included four trials, with a combined total of 1439 women in the review; each trial examined a different method of induction and we were unable to pool the results from trials.1. Vaginal PGE2 (two studies including 1028 women). There were no differences between women managed as outpatients versus inpatients for most review outcomes. There was no evidence of a difference between the likelihood of women requiring instrumental delivery in either setting (risk ratio (RR) 1.29; 95% confidence interval (CI) 0.79 to 2.13). The overall length of hospital stay was similar in the two groups.2. Controlled release PGE2 10 mg (one study including 300 women). There was no evidence of differences between groups for most review outcomes, including success of induction. During the induction period itself, women in the outpatient group were more likely to report high levels of satisfaction with their care (satisfaction rated seven or more on a nine-point scale, RR 1.42; 95% CI 1.11 to 1.81), but satisfaction scores measured postnatally were similar in the two groups.3. Foley catheter (one study including 111 women). There was no evidence of differences between groups for caesarean section rates, total induction time and the numbers of babies admitted to neonatal intensive care.

AUTHORS' CONCLUSIONS

The data available to evaluate the efficacy or potential hazards of outpatient induction are limited. It is, therefore, not yet possible to determine whether induction of labour is effective and safe in outpatient settings.

Acupuncture for induction of labour

BACKGROUND

This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. The use of complementary therapies is increasing and some women 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. The limited observational studies to date suggest acupuncture for induction of labour appears safe, 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 the effectiveness and safety of acupuncture for third trimester cervical ripening or induction of labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 November 2012), PubMed (1966 to 23 November 2012), Embase (1980 to 23 November 2012), Dissertation Abstracts (1861 to 23 November 2012), CINAHL (1982 to 23 November 2012), the WHO International Clinical Trials Registry Portal (ICTRP) (23 November 2012) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials comparing acupuncture used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, evaluated methodological quality and extracted data.

MAIN RESULTS

The original review included three trials and seven trials were excluded. This updated review includes 14 trials, and excludes eight trials. Three trials previously excluded due to no clinically relevant outcomes are now included. Eight new trials were included, and four new trials were excluded. We included 14 trials with data reporting on 2220 women.Trials reported on three primary outcomes only caesarean section, serious neonatal morbidity and maternal mortality. No trial reported on vaginal delivery not achieved within 24 hours; and uterine hyperstimulation with fetal heart rate (FHR) changes. There was no difference in caesarean deliveries between acupuncture and the sham control (average risk ratio (RR) 0.95, 95% confidence interval (CI) 0.69 to 1.30, six trials, 654 women), and acupuncture versus usual care (average RR 0.69, 95% CI 0.40, 1.20, six trials, 361 women). There was no difference in neonatal seizures between acupuncture and the sham group (RR 1.01, 95% CI 0.06 to 16.04, one trial, 364 women).There was some evidence of a change in cervical maturation for women receiving acupuncture compared with the sham control, (mean difference (MD) 0.40. 95%CI 0.11 to 0.69, one trial, 125 women), and when compared with usual care (MD 1.30, 95% CI 0.11 to 2.49, one trial, 67 women). The length of labour was shorter in the usual care group compared with acupuncture (average standardised mean difference (SMD) 0.67, 95% CI 0.18 to 1.17, one trial 68 women). There were no other statistically significant differences between groups. Few studies reported on many clinically relevant outcomes. One trial was at a low risk of bias on all domains.

AUTHORS' CONCLUSIONS

Overall, there have been few studies assessing the role of acupuncture for induction of labour. Before implications for clinical practice can be made there is a need for well-designed randomised controlled trials to evaluate the role of acupuncture to induce labour and for trials to assess clinically meaningful outcomes.

Morning versus evening induction of labour for improving outcomes

BACKGROUND

Induction of labour is a common intervention in obstetric practice. Traditionally, in most hospitals induction of labour with medication starts early in the morning, with the start of the working day for the day shift. In human and animal studies spontaneous onset of labour is proven to have a circadian rhythm with a preference for start of labour in the evening. Moreover, when spontaneous labour starts in the evening, the total duration of labour and delivery shortens and fewer obstetric interventions are needed. Based on these observations one might assume that starting induction of labour in the evening, in harmony with the circadian rhythm of natural birth, is more beneficial for both mother and child.

OBJECTIVES

To assess whether induction of labour starting in the evening, coinciding with the endogenous circadian rhythm, improves the outcome of labour compared with induction of labour starting in the early morning, organised to coincide with office hours.

SEARCH METHODS

We contacted the Trials Search Co-ordinator to search the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2012). In addition, we searched MEDLINE (1966 to 16 February 2012) and EMBASE (1980 to 16 February 2012).

SELECTION CRITERIA

We included all published and unpublished randomised controlled trials. We excluded trials that employed quasi-random methods of treatment allocation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias. Two review authors independently extracted data. Data were checked for accuracy. Where necessary, we contacted study authors for additional information.

MAIN RESULTS

The search resulted in 2693 articles that we screened on title and abstract for eligibility.Thirteen studies were selected for full text assessment. We included three randomised trials involving 1150 women. Two trials compared the administration of prostaglandins in the morning versus the evening in women with an unfavourable cervix, and one trial compared induction of labour in the morning versus the evening in women with a favourable cervix and/or ruptured membranes with intravenous oxytocin. Because of the different mechanism, we have reported results for these two comparisons separately.In the two trials comparing prostaglandins in the morning versus the evening there were few clinically significant differences between study groups for maternal or neonatal outcomes. One study reported a statistically significant preference by women to start induction of labour with prostaglandins in the morning.In the trial examining induction of labour with intravenous oxytocin, the number of neonatal admissions was statistically significantly increased in the group of women that started induction in the morning. This finding was unexpected, and while the trial authors offered some possible explanations for this, it is important that any future trials examine neonatal outcomes.

AUTHORS' CONCLUSIONS

Taking into account women's preferences that favoured administration of prostaglandins in the morning, we conclude that caregivers should preferably consider administering prostaglandins in the morning.There is no strong evidence that induction of labour with intravenous oxytocin in the evening is more or less effective than induction in the morning. Consideration may be given to start induction of labour with oxytocin in the evening when indicated.

Induction of labor and risk of postpartum hemorrhage in low risk parturients

Objective

Labor induction is an increasingly common procedure, even among women at low risk, although evidence to assess its risks remains sparse. Our objective was to assess the association between induction of labor and postpartum hemorrhage (PPH) in low-risk parturients, globally and according to its indications and methods.

Method

Population-based case-control study of low-risk women who gave birth in 106 French maternity units between December 2004 and November 2006, including 4450 women with PPH, 1125 of them severe, and 1744 controls. Indications for labor induction were standard or non-standard, according to national guidelines. Induction methods were oxytocin or prostaglandins. Multilevel multivariable logistic regression modelling was used to test the independent association between induction and PPH, quantified as odds ratios.

Results

After adjustment for all potential confounders, labor induction was associated with a significantly higher risk of PPH (adjusted odds ratio, AOR1.22, 95%CI 1.04–1.42). This excess risk was found for induction with both oxytocin (AOR 1.52, 95%CI 1.19–1.93 for all and 1.57, 95%CI 1.11–2.20 for severe PPH) and prostaglandins (AOR 1.21, 95%CI 0.97–1.51 for all and 1.42, 95%CI 1.04–1.94 for severe PPH). Standard indicated induction was significantly associated with PPH (AOR1.28, 95%CI 1.06–1.55) while no significant association was found for non-standard indicated inductions.

Conclusion

Even in low risk women, induction of labor, regardless of the method used, is associated with a higher risk of PPH than spontaneous labor. However, there was no excess risk of PPH in women who underwent induction of labor for non-standard indications. This raises the hypothesis that the higher risk of PPH associated with labor induction may be limited to unfavorable obstetrical situations.

The efficacy of early amniotomy in nulliparous labor induction: a randomized controlled trial

OBJECTIVE

The purpose of this study was to assess whether early amniotomy reduces the duration of labor or increases the proportion of subjects who are delivered within 24 hours in nulliparous patients who undergo labor induction.

STUDY DESIGN

We performed a randomized controlled trial that compared early amniotomy to standard management in nulliparous labor inductions. Inclusion criteria were nulliparity, singleton, term gestation, and a need for labor induction. Subjects were assigned randomly to early amniotomy (artificial rupture of membranes, ≤4 cm) or to standard treatment. There were 2 primary outcomes: (1) time from induction initiation to delivery and (2) the proportion of women who delivered within 24 hours.

RESULTS

Early amniotomy shortens the time to delivery by >2 hours (19.0 vs 21.3 hours) and increases the proportion of induced nulliparous women who deliver within 24 hours (68% vs 56%). These improvements in labor outcomes did not come at the expense of increased complications.

CONCLUSION

Early amniotomy is a safe and efficacious adjunct in nulliparous labor inductions.

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 simplicity of preservation, lower cost and reduction of the side effects.

OBJECTIVES

To determine the effects of mechanical methods for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment, prostaglandins (vaginal and intracervical prostaglandin E2 (PGE2), misoprostol) and oxytocin.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2011) and bibliographies of relevant papers. We updated this search on 16 January 2012 and added the 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 methods listed above it on a predefined list of methods of labour. A comparison with amniotomy will be added, should this comparison be made in future trials.Different types of intervention have been considered as mechanical methods: (1) introduction of laminaria tents, or their synthetic equivalent (Dilapan), into the cervical canal; (2) the introduction of a catheter through the cervix into the extra-amniotic space, with or without traction; (3) use of a catheter to inject fluidsin the extra-amniotic spaceIn addition, we made other comparisons: (1) specific mechanical methods (balloon catheter and laminaria tents) compared with any prostaglandins or with oxytocin; (2) addition of prostaglandins or oxytocin to mechanical methods compared with prostaglandins alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data.

MAIN RESULTS

For this update we have included a further 27 studies. The review includes 71 randomised controlled trials (total of 9722 women), ranging from 39 to 588 women per study. Most studies reported on caesarean section, all other outcomes are based on substantially fewer women. Four additional studies are ongoing.Mechanical methods versus no treatment: one study (48 woman) reported on women who did not achieve vaginal delivery within 24 hours (risk ratio (RR) 0.90; 95% confidence interval (CI) 0.64 to 1.26). The risk of caesarean section was similar between groups (six studies; 416 women, RR 1.00; 95% CI 0.76 to 1.30). There were no cases of severe neonatal and maternal morbidity.Mechanical methods versus vaginal PGE2 (17 studies;1894 woman): The proportion of women who did not achieve vaginal delivery within 24 hours was not significantly different (three studies; 586 women RR 1.72; 95% CI 0.90 to 3.27); however, for the subgroup of multiparous women the risk of not achieving delivery within 24 hours was higher (one study; 147 women RR 4.38, 95% CI 1.74 to 10.98), with no increase in caesarean sections (RR 1.19, 95% CI 0.62-2.29). Compared with intracervical PGE2 (14 studies;1784 women and misoprostol there was no significant difference in the proportion of women not achieving vaginal delivery within 24 hours.Mechanical methods reduced the risk of hyperstimulation with fetal heart rate changes when compared with vaginal prostaglandins: vaginal PGE2 (eight studies; 1203 women, RR 0.16; 95% CI 0.06 to 0.39) and misoprostol (3% versus 9%) (nine studies; 1615 women, RR 0.37; 95% CI 0.25 to 0.54). Risk of caesarean section between mechanical methods and prostaglandins was comparable. Serious neonatal and maternal morbidity were infrequently reported and did not differ between the groups.Mechanical methods compared with induction with oxytocin (reduced the risk of caesarean section (five studies; 398 women, RR 0.62; 95% CI 0.42 to 0.90). The likelihood of vaginal delivery within 24 hours was not reported. Hyperstimulation with fetal heart rate changes was reported in one study (200 participants), and did not differ. There were no reported cases of severe maternal or neonatal morbidity.

AUTHORS' CONCLUSIONS

Induction of labour using mechanical methods results in similar caesarean section rates as prostaglandins, for a lower risk of hyperstimulation. Mechanical methods do not increase the overall number of women not delivered within 24 hours, however the proportion of multiparous women who did not achieve vaginal delivery within 24 hours was higher when compared with vaginal PGE2. Compared with oxytocin, mechanical methods reduce the risk of caesarean section.

Role of aldo-keto reductase enzymes in mediating the timing of parturition

A better understanding of the mechanisms underlying parturition would provide an important step toward improving therapies for the prevention of preterm labor. Aldo–keto reductases (AKR) from the 1D, 1C, and 1B subfamilies likely contribute to determining the timing of parturition through metabolism of progesterone and prostaglandins. Placental AKR1D1 (human 5β reductase) likely contributes to the maintenance of pregnancy through the formation of 5β-dihydroprogesterone (DHP). AKR1C1, AKR1C2, and AKR1C3 catalyze the 20-ketosteroid and 3-ketosteroid reduction of progestins. They could therefore eliminate tocolytic progestins at term. Activation of the F prostanoid receptor by its ligands also plays a critical role in initiation of labor. AKR1C3 and AKR1B1 have prostaglandin (PG) F synthase activities that likely contribute to the initiation of labor. AKR1C3 converts PGH₂ to PGF_2α and PGD₂ to 9α,11β-PGF₂. AKR1B1 also reduces PGH₂ to PGF_2α, but does not form 9α,11β-PGF₂. Consistent with the potential role for AKR1C3 in the initiation of parturition, indomethacin, which is a potent and isoform selective inhibitor of AKR1C3, has long been used for tocolysis.

Nitric oxide donors for cervical ripening and induction of labour

BACKGROUND

Sometimes it is necessary to bring on labour artificially because of safety concerns for the mother or baby. This review is one of a series of reviews of methods of labour induction using a standardised protocol.Induction of labour occurs in approximately 20% of pregnancies in the UK. The ideal agent for induction of labour would induce cervical ripening without causing uterine contractions. Currently most commonly used cervical ripening or induction agents result in uterine activity or contractions, or both. Cervical ripening without uterine contractility could occur safely in an outpatient setting and it may be expected that this would result in greater maternal satisfaction and lower costs.

OBJECTIVES

To determine the effects of nitric oxide (NO) donors for third trimester cervical ripening or induction of labour, in comparison with placebo or no treatment or other treatments from a predefined hierarchy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2010) and the reference lists of trial reports and reviews.

SELECTION CRITERIA

Clinical trials comparing NO donors for cervical ripening or labour induction to other methods listed above it on a predefined list of methods of labour induction. The trials include some form of random allocation to either group; and report one or more of the prestated outcomes. NO donors (isosorbide mononitrate, nitroglycerin and sodium nitroprusside) are compared to other methods listed above it on a predefined list of methods of labour induction.

DATA COLLECTION AND ANALYSIS

This review is part of a series of reviews focusing on methods of induction of labour. Three review authors independently assessed trials for inclusion, assessed risk of bias and extracted data.

MAIN RESULTS

We considered 19 trials; we included 10 (including a total of 1889 women) trials, excluded eight trials and one trial report is awaiting classification. Included studies compared NO donors to placebo, vaginal prostaglandin E2, intracervical PGE2 and vaginal misoprostol. All included studies were of a generally high standard with a low risk of bias.There are very limited data available to compare nitric oxide donors to any other induction agent. There is no evidence of any difference between any of the prespecified outcomes when comparing NO donors to other induction agents, with the exception of an increase in maternal side effects.

AUTHORS' CONCLUSIONS

NO donors do not appear currently to be a useful tool in the process of induction of labour. More studies are required to examine how NO donors may work alongside established induction of labour protocols, especially those based in outpatient settings.

Shortening the induction delivery interval with prostaglandins: a randomized controlled trial of solo or in combination

OBJECTIVE

To compare the efficacy and safety of misoprostol alone with dinoprostone followed by misoprostol, all inserted intravaginally in induction of labor at term and the obstetrical outcome.

MATERIAL AND METHODS

A pilot study comprising 111 primigravidae, >37 gestational weeks with singleton pregnancy in cephalic presentation having an unfavorable Bishop score admitted for labor induction, were considered and randomly allocated into two groups. In group I (n=55) with intravaginal 25mcg misoprostol 4 hourly (six doses at the most) and and group II (n=56), with dinoprostone 0.5mg followed eight hours later by 25mcg misoprostol induction to vaginal delivery time was found to be significantly different, being 14.8 h in group-I and shorter in group-II with a mean of 11.6 h. Vaginal delivery rates within 12 h (groups-I and -II: 47.2%, as compared to 60.7%, respectively) were found to be higher with dinoprostone-misoprostol induction, as well as vaginal delivery rates in 24 h, 80.0% and 91.1%. The need for oxytocin augmentation was more frequent in the misoprostol than in the dinoprostone-misoprostol group, (61.8%, and 39.3%), and all these observations were statistically significant. Abnormal foetal heart rate pattern occurred more frequently (18.2%) in group-I in contrast to 5.3% in group-II, as was the incidence rate of (18.2%) who had passage of meconium in group-I, this rate being significantly different from group-II having meconium passage in 3 cases, a rate of 5.3%.

CONCLUSION

Using dinoprostone followed by vaginal misoprostol is safe and effective for induction of labor with less need for oxytocin augmentation and shorter induction delivery interval.

Cost-effectiveness analysis of prostaglandin E2 gel for the induction of labour at term

OBJECTIVE

To estimate the cost-effectiveness of prostaglandin E2 (dinoprostone) vaginal gel for the induction of labour at term from the perspective of the UK's National Health Service.

DESIGN

Economic evaluation conducted as part of a randomised controlled trial.

SETTING

Maternity department at a major teaching hospital in London, UK.

POPULATION

A cohort of 165 pregnant women presenting as cephalic between 36(+⁶) and 41(+⁶) weeks of gestation, for whom induction of labour was deemed necessary.

METHODS

Either 3-mg Prostin E2 vaginal tablets or 1- or 2-mg Prostin E2 vaginal gel were administered at 6-hourly intervals.

MAIN OUTCOME MEASURES

Incremental cost per hour prevented between induction and delivery. The nonparametric bootstrap method was used to construct cost-effectiveness acceptability curves and estimate net benefits at alternative cost-effectiveness thresholds.

RESULTS

Women receiving the gel accrued nonsignificantly higher costs (incremental cost £630; bootstrap 95% CI -£353, £2320; P = 0.43), and experienced a significantly reduced interval between induction and delivery (median of 1400 versus 1780 minutes; mean of 1711 versus 2765 minutes; P = 0.03). The incremental cost per hour prevented from induction of labour to delivery was estimated at £36. At a cost-effectiveness threshold of £100 per hour of care prevented, the probability that the gel is cost-effective was estimated at 0.83, and the mean net benefit to the health services was estimated at £1121 (bootstrap 95% CI -£1133, £3379). The results were sensitive to the inclusion of neonatal costs in the analysis and the value of the cost-effectiveness threshold. Notably, excluding neonatal costs increased the probability that the gel is cost-effective at a cost-effectiveness threshold of £100 per hour of care prevented to 0.99.

CONCLUSIONS

This study suggests that prostaglandin E2 gel is probably more cost-effective than prostaglandin E2 tablets for the induction of labour at term. Given that the results are applicable to the general obstetric population requiring induction of labour at term, decision-makers should consider the likely economic impacts of their implementation.

Vaginal misoprostol for cervical ripening and induction of labour

BACKGROUND

Misoprostol (Cytotec, Searle) is a prostaglandin E1 analogue widely used for off-label indications such as induction of abortion and of labour. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of vaginal misoprostol for third trimester cervical ripening or induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group's Trials Register (November 2008) and bibliographies of relevant papers. We updated this search on 30 April 2010 and added the results to the awaiting classification section.

SELECTION CRITERIA

Clinical trials comparing vaginal misoprostol used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

We developed a strategy to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction.We used fixed-effect Mantel-Haenszel meta-analysis for combining dichotomous data.If we identified substantial heterogeneity (I² greater than 50%), we used a random-effects method.

MAIN RESULTS

We included 121 trials. The risk of bias must be kept in mind as only 13 trials were double blind.Compared to placebo, misoprostol was associated with reduced failure to achieve vaginal delivery within 24 hours (average relative risk (RR) 0.51, 95% confidence interval (CI) 0.37 to 0.71). Uterine hyperstimulation, without fetal heart rate (FHR) changes, was increased (RR 3.52 95% CI 1.78 to 6.99).Compared with vaginal prostaglandin E2, intracervical prostaglandin E2 and oxytocin, vaginal misoprostol was associated with less epidural analgesia use, fewer failures to achieve vaginal delivery within 24 hours and more uterine hyperstimulation. Compared with vaginal or intracervical prostaglandin E2, oxytocin augmentation was less common with misoprostol and meconium-stained liquor more common.Lower doses of misoprostol compared to higher doses were associated with more need for oxytocin augmentation and less uterine hyperstimulation, with and without FHR changes.We found no information on women's views.

AUTHORS' CONCLUSIONS

Vaginal misoprostol in doses above 25 mcg four-hourly was more effective than conventional methods of labour induction, but with more uterine hyperstimulation. Lower doses were similar to conventional methods in effectiveness and risks. The authors request information on cases of uterine rupture known to readers. The vaginal route should not be researched further as another Cochrane review has shown that the oral route of administration is preferable to the vaginal route. Professional and governmental bodies should agree guidelines for the use of misoprostol, based on the best available evidence and local circumstances.

Misoprostol for induction of labour to terminate pregnancy in the second or third trimester for women with a fetal anomaly or after intrauterine fetal death

BACKGROUND

A woman may need to give birth prior to the spontaneous onset of labour in situations where the fetus has died in utero (also called a stillbirth), or for the termination of pregnancy where the fetus, if born alive would not survive or would have a permanent handicap. Misoprostol is a prostaglandin medication that can be used to induce labour in these situations.

OBJECTIVES

To compare the benefits and harms of misoprostol to induce labour to terminate pregnancy in the second and third trimester for women with a fetal anomaly or after intrauterine fetal death when compared with other methods of induction of labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2009).

SELECTION CRITERIA

Randomised controlled trials comparing misoprostol with placebo or no treatment, or any other method of induction of labour, for women undergoing induction of labour to terminate pregnancy in the second and third trimester following an intrauterine fetal death or for fetal anomalies.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included 38 studies (3679 women).Nine studies included pregnancies after intrauterine deaths, five studies included termination of pregnancies because of fetal anomalies when the fetus was still alive and the rest (24) presented the pooled data for intrauterine deaths, fetal anomalies and social reasons.When compared with agents that have traditionally been used to induce labour in this setting (for example, gemeprost, prostaglandin E(2) and prostaglandin F(2alpha)), vaginal misoprostol is as effective in ensuring vaginal birth within 24 hours, with a similar induction to birth interval. Vaginal misoprostol is associated with a reduction in the occurrence of maternal gastrointestinal side effects such as nausea, vomiting and diarrhoea when compared with other prostaglandin preparations. While the different treatments involving various prostaglandin preparations appear comparable for the reported outcomes, the information available regarding rare maternal complications, such as uterine rupture, is limited.

AUTHORS' CONCLUSIONS

The use of vaginal misoprostol in the termination of second and third trimester of pregnancy is as effective as other prostaglandin preparations (including cervagem, prostaglandin E(2) and prostaglandin F(2alpha)), and more effective than oral administration of misoprostol. However, important information regarding maternal safety, and in particular the occurrence of rare outcomes such as uterine rupture, remains limited. Future research efforts should be directed towards determining the optimal dose and frequency of administration, with particular attention to standardised reporting of all relevant outcomes and assessment of rare adverse events. Further information is required about the use of sublingual misoprostol in this setting.

Intravenous oxytocin alone for cervical ripening and induction of labour

BACKGROUND

Oxytocin is the commonest induction agent used worldwide. It has been used alone, in combination with amniotomy or following cervical ripening with other pharmacological or non-pharmacological methods.

OBJECTIVES

To determine the effects of oxytocin alone for third trimester cervical ripening and induction of labour in comparison with other methods of induction of labour or placebo/no treatment.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2009) and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing intravenous oxytocin with placebo or no treatment, or with prostaglandins (vaginal or intracervical) for third trimester cervical ripening or labour induction.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and carried out data extraction.

MAIN RESULTS

Sixty-one trials (12,819 women) are included.When oxytocin inductions were compared with expectant management, fewer women failed to deliver vaginally within 24 hours (8.4% versus 53.8%, risk ratio (RR) 0.16, 95% confidence interval (CI) 0.10 to 0.25). There was a significant increase in the number of women requiring epidural analgesia (RR 1.10, 95% CI 1.04 to 1.17). Fewer women were dissatisfied with oxytocin induction in the one trial reporting this outcome (5.9% versus 13.7%, RR 0.43, 95% CI 0.33 to 0.56).Compared with vaginal prostaglandins, oxytocin increased unsuccessful vaginal delivery within 24 hours in the two trials reporting this outcome (70% versus 21%, RR 3.33, 95% CI 1.61 to 6.89). There was a small increase in epidurals when oxytocin alone was used (RR 1.09, 95% CI 1.01 to 1.17).Most of the studies included women with ruptured membranes, and there was some evidence that vaginal prostaglandin increased infection in mothers (chorioamnionitis RR 0.66, 95% CI 0.47 to 0.92) and babies (use of antibiotics RR 0.68, 95% CI 0.53 to 0.87). These data should be interpreted cautiously as infection was not pre-specified in the original review protocol.When oxytocin was compared with intracervical prostaglandins, there was an increase in unsuccessful vaginal delivery within 24 hours (50.4% versus 34.6%, RR 1.47, 95% CI 1.10 to 1.96) and an increase in caesarean sections (19.1% versus 13.7%, RR 1.37, 95% CI 1.08 to 1.74) in the oxytocin group.

AUTHORS' CONCLUSIONS

Comparison of oxytocin with either intravaginal or intracervical PGE2 reveals that the prostaglandin agents probably increase the chances of achieving vaginal birth within 24 hours. Oxytocin induction may increase the rate of interventions in labour.A suggestion that for women with prelabour rupture of membranes induction with vaginal prostaglandin may increase risk of infection for mother and baby warrants further study.

Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term

BACKGROUND

Prostaglandins have been used for induction of labour since the 1960s. Initial work focused on prostaglandin F2a as prostaglandin E2 was considered unsuitable for a number of reasons. With the development of alternative routes of administration, comparisons were made between various formulations of vaginal prostaglandins.

OBJECTIVES

To determine the effects of vaginal prostaglandins E2 and F2a for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment or other vaginal prostaglandins (except misoprostol).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2009) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

We assessed studies and extracted data independently.

MAIN RESULTS

Sixty-three (10,441 women) have been included.Vaginal prostaglandin E2 compared with placebo or no treatment reduced the likelihood of vaginal delivery not being achieved within 24 hours (18.1% versus 98.9%, risk ratio (RR) 0.19, 95% confidence interval (CI) 0.14 to 0.25, two trials, 384 women). The risk of the cervix remaining unfavourable or unchanged was reduced (21.6% versus 40.3%, RR 0.46, 95% CI 0.35 to 0.62, five trials, 467 women); and the risk of oxytocin augmentation reduced (35.1% versus 43.8%, RR 0.83, 95% CI 0.73 to 0.94, 12 trials, 1321 women) when PGE2 was compared to placebo. There was no evidence of a difference between caesarean section rates, although the risk of uterine hyperstimulation with fetal heart rate changes was increased (4.4% versus 0.49%, RR 4.14, 95% CI 1.93 to 8.90, 14 trials, 1259 women).PGE2 tablet, gel and pessary appear to be as efficacious as each other and the use of sustained release PGE2 inserts appear to be associated with a reduction in instrumental vaginal delivery rates (9.9 % versus 19.5%, RR 0.51, 95% CI 0.35 to 0.76, NNT 10 (6.7 to 24.0), five trials, 661 women) when compared to vaginal PGE2 gel or tablet.

AUTHORS' CONCLUSIONS

PGE2 increases successful vaginal delivery rates in 24 hours and cervical favourability with no increase in operative delivery rates. Sustained release vaginal PGE2 is superior to vaginal PGE2 gel with respect to some outcomes studied.Further research is needed to assess the best vehicle for delivering vaginal prostaglandins and this should, where possible, include some examination of the cost-analysis.

What (not) to do before delivery? Prevention of fetal meconium release and its consequences

BACKGROUND

Meconium-stained amniotic fluid is a common occurrence which places the mother at risk of escalating obstetric interventions, and the baby at risk of meconium aspiration syndrome.

METHODS

The Cochrane Library was searched for interventions related to care before delivery with useful evidence on the outcomes 'meconium-stained amniotic fluid' and 'meconium aspiration syndrome'.

FINDINGS

Curtailment of post-term pregnancy reduces the occurrence of meconium-stained amniotic fluid, and meconium aspiration syndrome. Uterine stimulants, particularly misoprostol, are associated with occurrence of meconium-stained amniotic fluid. Amniotomy during labour may be a risk factor for meconium aspiration syndrome. There is little research evidence on the benefits or otherwise of obstetric interventions such as expedited delivery for meconium-stained liquor without other evidence of fetal distress. Amnioinfusion for meconium-stained amniotic fluid improves neonatal outcome only in settings with limited peripartum surveillance. There is insufficient evidence to support the use of amnioinfusion for meconium-stained liquor in settings with adequate peripartum surveillance.

Mifepristone for induction of labour

BACKGROUND

The steroid hormone, progesterone, inhibits contractions of the pregnant uterus at all gestations. Antiprogestins (including mifepristone) have been developed to antagonise the action of progesterone, and have a recognised role in medical termination of early or mid-trimester pregnancy. Animal studies have suggested that mifepristone may also have a role in inducing labour in late pregnancy.

OBJECTIVES

To determine the effects of mifepristone for third trimester cervical ripening or induction of labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register and reference lists of relevant papers (May 2009).

SELECTION CRITERIA

Clinical trials comparing mifepristone used for third trimester cervical ripening or labour induction with placebo/no treatment or other labour induction methods.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. For this update, two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Ten trials (1108 women) are included. Compared to placebo, mifepristone treated women were more likely to be in labour or to have a favourable cervix at 48 hours (risk ratio (RR) 2.41, 95% confidence intervals (CI) 1.70 to 3.42) and this effect persisted at 96 hours (RR 3.40, 95% CI 1.96 to 5.92). They were less likely to need augmentation with oxytocin (RR 0.80, 95% CI 0.66 to 0.97). Mifepristone treated women were less likely to undergo caesarean section (RR 0.74, 95% CI 0.60 to 0.92) but more likely to have an instrumental delivery (RR 1.43, 95% CI 1.04 to 1.96). Women receiving mifepristone were less likely to undergo a caesarean section as a result of failure to induce labour (RR 0.40, 95% CI 0.20 to 0.80). There is insufficient evidence to support a particular dose but a single dose of 200 mg mifepristone appears to be the lowest effective dose for cervical ripening (increased likelihood of cervical ripening at 72 hours (RR 2.13, 95% CI 1.15 to 3.97). Abnormal fetal heart rate patterns were more common after mifepristone treatment (RR 1.85, 95% CI 1.17 to 2.93), but there was no evidence of differences in other neonatal outcomes. There is insufficient information on the occurrence of uterine rupture/dehiscence in the reviewed studies.

AUTHORS' CONCLUSIONS

There is insufficient information available from clinical trials to support the use of mifepristone to induce labour. However, the studies suggest that mifepristone is better than placebo in reducing the likelihood of caesarean sections being performed for failed induction of labour; therefore, this may justify future trials comparing mifepristone with the routine cervical ripening agents currently in use. There is little information on effects on the baby.

Anaesthesiological considerations on tocolytic and uterotonic therapy in obstetrics

AIM

Significant side effects of tocolytic and uterotonic substances may be of concern to the anaesthesiologist. Recently, new drugs have been introduced having less side effects for both the mother and the neonate.

METHODS

A literature search was undertaken mainly focusing on meta-analyses, to review the possible side effects that might affect the course of anaesthesia and to suggest which precautions should be considered to prevent the occurrence of significant interactions with anaesthetic manipulations and drugs.

RESULTS

Magnesium sulphate has a proven benefit in lowering systolic blood pressure and preventing the occurrence of eclampsia, but not as a tocolytic. beta-adrenergic agonists are being abandoned due to the availability of tocolytic agents causing less side effects. Calcium channel blockers (CCB) are frequently used but can cause major maternal cardiovascular complications. Nitroglycerin seems to be appreciated as an acute tocolytic rather than a routine substance during pre-term labour. Cyclo-oxygenase-2 inhibitors are still under investigation but their tocolytic benefit is questionable mainly due to foetal side effects. Atosiban is considered the first-choice tocolytic. With respect to oxytocic drugs, oxytocine, prostaglandines and methylergometrine may all cause serious side effects especially when combined. The cardiovascular side effects of prostaglandins and methylergometrine can be life-threatening. Both oxytocin and carbetocin have a rather low risk for maternal complications.

CONCLUSION

Atosiban and CCB are at least as effective tocolytic agents as beta-mimetics but have significantly less side effects. Magnesium sulphate can cause neuromuscular blockade, especially when combined with CCB. Concerning oxytocic agents, short-acting oxyctocin and long-acting carbetocin have the least side effects as compared with prostaglandins and methylergometrine.

Reducing stillbirths: interventions during labour

BACKGROUND

Approximately one million stillbirths occur annually during labour; most of these stillbirths occur in low and middle-income countries and are associated with absent, inadequate, or delayed obstetric care. The low proportion of intrapartum stillbirths in high-income countries suggests that intrapartum stillbirths are largely preventable with quality intrapartum care, including prompt recognition and management of intrapartum complications. The evidence for impact of intrapartum interventions on stillbirth and perinatal mortality outcomes has not yet been systematically examined.

METHODS

We undertook a systematic review of the published literature, searching PubMed and the Cochrane Library, of trials and reviews (N = 230) that reported stillbirth or perinatal mortality outcomes for eight interventions delivered during labour. Where eligible randomised controlled trials had been published after the most recent Cochrane review on any given intervention, we incorporated these new trial findings into a new meta-analysis with the Cochrane included studies.

RESULTS

We found a paucity of studies reporting statistically significant evidence of impact on perinatal mortality, especially on stillbirths. Available evidence suggests that operative delivery, especially Caesarean section, contributes to decreased stillbirth rates. Induction of labour rather than expectant management in post-term pregnancies showed strong evidence of impact, though there was not enough evidence to suggest superior safety for the fetus of any given drug or drugs for induction of labour. Planned Caesarean section for term breech presentation has been shown in a large randomised trial to reduce stillbirths, but the feasibility and consequences of implementing this intervention routinely in low-/middle-income countries add caveats to recommending its use. Magnesium sulphate for pre-eclampsia and eclampsia is effective in preventing eclamptic seizures, but studies have not demonstrated impact on perinatal mortality. There was limited evidence of impact for maternal hyperoxygenation, and concerns remain about maternal safety. Transcervical amnioinfusion for meconium staining appears promising for low/middle income-country application according to the findings of many small studies, but a large randomised trial of the intervention had no significant impact on perinatal mortality, suggesting that further studies are needed.

CONCLUSION

Although the global appeal to prioritise access to emergency obstetric care, especially vacuum extraction and Caesarean section, rests largely on observational and population-based data, these interventions are clearly life-saving in many cases of fetal compromise. Safe, comprehensive essential and emergency obstetric care is particularly needed, and can make the greatest impact on stillbirth rates, in low-resource settings. Other advanced interventions such as amnioinfusion and hyperoxygenation may reduce perinatal mortality, but concerns about safety and effectiveness require further study before they can be routinely included in programs.

Outpatient versus inpatient induction of labour for improving birth outcomes

BACKGROUND

More than 20% of women undergo induction of labour in some countries. The different methods used to induce labour have been the focus of previous reviews, but the setting in which induction takes place (hospital versus outpatient settings) may have implications for maternal satisfaction and costs. It is not known whether some methods of induction that are effective and safe in hospital are suitable in outpatient settings.

OBJECTIVES

To assess the effects on outcomes for mothers and babies of induction of labour for women managed as outpatients versus inpatients.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2008).

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised trials in which inpatient and outpatient methods of cervical ripening or induction of labour have been compared.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial reports for inclusion. Two review authors carried out data extraction and assessment of risk of bias independently.

MAIN RESULTS

We included three trials, with a combined total of 612 women in the review; each examined a different method of induction and we were unable to pool the results from trials.1. Vaginal PGE2 (One study including 201 women). There were no differences between women managed as out- versus inpatients for most review outcomes. Women in the outpatient group were more likely to have instrumental deliveries (risk ratio (RR) 1.74; 95% confidence interval (CI) 1.03 to 2.93). The overall length of hospital stay was similar in the two groups.2. Controlled release PGE2 10mg (one study including 300 women). There was no evidence of differences between groups for most review outcomes, including success of induction. During the induction period itself, women in the outpatient group were more likely to report high levels of satisfaction with their care (satisfaction rated seven or more on a nine-point scale RR 1.42; 95% CI 1.11 to 1.81), but satisfaction scores measured postnatally were similar in the two groups.3. Foley catheter (one study including 111 women). There was no evidence of differences between groups for caesarean section rates, total induction time and the numbers of babies admitted to neonatal intensive care.

AUTHORS' CONCLUSIONS

The data available to evaluate the efficacy or potential hazards of outpatient induction are limited. It is, therefore, not yet possible to determine whether induction of labour is effective and safe in outpatient settings.

Morning versus evening induction of labour for improving outcomes

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess whether induction of labour starting in the evening, coinciding with the endogenous circadian rhythm, improves the outcome of labour compared to induction of labour starting in the early morning, organised to coincide with office hours.

Intracervical prostaglandins for induction of labour

BACKGROUND

Prostaglandins have been used for cervical ripening and induction of labour since the 1970s. The goal of the administration of prostaglandins in the process of induction of labour is to achieve cervical ripening before the onset of contractions. One of the routes of administration that was proposed is intracervical. Using this route, prostaglandins are less easy to administer and the need for exposing the cervix may cause discomfort to the woman.

OBJECTIVES

To determine the effects of intracervical prostaglandins for third trimester cervical ripening or induction of labour compared with placebo/no treatment and with vaginal prostaglandins (except misoprostol).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials comparing intracervical prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods (vaginal prostaglandins, except misoprostol).

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction.

MAIN RESULTS

Fifty-six trials (7738 women) are included. INTRACERVICAL PGE2 WITH PLACEBO/NO TREATMENT: 28 TRIALS, 3764 WOMEN: Four studies reported the number of women who did not achieve vaginal delivery within 24 hours, showing a decreased risk with PGE2 (relative risk (RR) 0.61; 95% confidence interval (CI) 0.47 to 0.79). There was a small, and statistically non-significant, reduction of the risk of caesarean section when PGE2 was used (RR 0.88; 95% CI 0.77 to 1.00). The finding was statistically significant in a subgroup of women with intact membranes and unfavourable cervix only (RR 0.82; 95% CI 0.68 to 0.98). The risk of hyperstimulation with fetal heart rate (FHR) changes was not significantly increased (RR 1.21; 95% CI 0.72 to 2.05). However, the risk of hyperstimulation without FHR changes was significantly increased (RR 1.59; 95% CI 1.09 to 2.33. INTRACERVICAL PGE2 WITH INTRAVAGINAL PGE2: 29 TRIALS, 3881 WOMEN: The risk of not achieving vaginal delivery within 24 hours was increased with intracervical PGE2 (RR 1.26; 95% CI 1.12 to 1.41). There was no change in the risk of caesarean section (RR 1.07; 95% CI 0.93 to 1.22). The risks of hyperstimulation with FHR changes (RR 0.76; 95% CI 0.39 to 1.49) and without FHR changes (RR 0.80; 95% CI 0.56 to 1.15) were non-significantly different with the two methods of PGE2 administration. Only one trial with small sample size reported on women's views, with no difference between groups. INTRACERVICAL PGE2 LOW DOSE WITH INTRACERVICAL PGE2 HIGH DOSE: TWO TRIALS, 102 WOMEN: The trials are too small to provide any useful information.

AUTHORS' CONCLUSIONS

Intracervical prostaglandins are effective compared to placebo, but appear inferior when compared to intravaginal prostaglandins.

Comparing two dinoprostone agents for cervical ripening and induction of labor: a randomized trial

OBJECTIVE

To compare dinoprostone gel and insert in achieving successful vaginal delivery in nulliparous and multiparous women.

STUDY DESIGN

220 nulliparous and 100 multiparous with a Bishop score < or =7 were randomized to receive dinoprostone either gel or insert for cervical ripening. The main outcome measures were the rate and latency of vaginal delivery.

RESULTS

In nulliparous women no significant differences were found between the gel and insert groups in the rate of vaginal delivery (85.6% vs. 80.7%) delivery < or =12 (36.8% vs. 32.9%) and < or =24h (85.3% vs. 93.4%) regardless of the preinduction Bishop score. Nulliparous with Bishop score < or =4 treated with the insert had a decreased risk (p<0.05) of post partum hemorrhage (4.8%) when compared with nulliparous treated with gel (16.7%). On the contrary, in multiparous the time to delivery interval was significantly shorter in the gel treated group (9.9+/-4.9h vs. 13.1+/-5h; p<0.001) with more patients delivering vaginally < or =12h (75% vs. 37.5%, p<0.001), regardless of the preinduction Bishop score.

CONCLUSION

Both dinoprostone gel and insert are efficient in achieving cervical ripening and successful labor in nulliparous and multiparous. In multiparous, however, the gel significantly reduces the time to vaginal delivery with more patients delivering vaginally < or =12h, regardless of the Bishop score.

Sublingual compared with vaginal misoprostol for labour induction at term: a randomised controlled trial

OBJECTIVE

To compare the efficacy and safety of 50 microg of sublingual misoprostol with 25 microg of vaginal misoprostol administered for labour induction at term. Design Double-blinded, randomised controlled trial. Setting University Hospital, Kaunas, Lithuania. Sample A total of 140 women at term with indications for labour induction. Methods Women were randomised to receive either 50 microg of sublingual misoprostol with vaginal placebo (n = 70) or sublingual placebo with 25 microg of vaginal misoprostol (n = 70) every 4 hours (maximum six doses). Main outcome measures The number of women delivering vaginally within 24 hours of labour induction. Results Fifty-eight women (83%) in the sublingual misoprostol group and 53 (76%) in the vaginal misoprostol group delivered vaginally within 24 hours [relative risk (RR) 1.1, 95% confidential interval (CI) 0.9-1.3]. However, the induction to vaginal delivery time was significantly shorter in the sublingual group (15.0 +/- 3.7 hours) compared with the vaginal group (16.7 +/- 4.1 hours, P = 0.03). The incidence of tachysystole was more than three-fold higher in the sublingual than in the vaginal group (14 versus 4.3%; RR 3.3, 95% CI 0.9-11.6), but this was not statistically significant. There were no significant differences in the incidence of hypertonus or hyperstimulation syndrome, mode of delivery, interventions for fetal distress or neonatal outcomes between the two groups. Conclusion A 50 microg of sublingual misoprostol 4 hourly for labour induction at term seems to have similar efficacy as 25 microg of vaginal misoprostol. Further studies on safety with larger numbers of women need to be conducted before routine sublingual misoprostol use in this setting.

Induction of labor at term using isosorbide mononitrate simultaneously with dinoprostone compared to dinoprostone treatment alone: a randomized, controlled trial

OBJECTIVE

We aimed to determine whether isosorbide mononitrate (IMN) given simultaneously with dinoprostone in term pregnancies is superior to dinoprostone alone to promote delivery.

STUDY DESIGN

One hundred and twenty nulliparous women at term were randomly assigned to receive per vaginam IMN 40 mg or placebo in addition to 3 mg dinoprostone 2 times daily for up to 2 days. Analysis was by intention to treat.

RESULTS

Baseline characteristics of both groups were comparable. The induction to delivery intervals did not differ between the IMN and the placebo group (26.4 +/- 14.4 vs 23.4 +/- 14.8 hours, P = .408). IMN resulted in more headache compared to placebo (32/55 [58.2%] vs 2/55 [3.6%], P < .001).

CONCLUSION

Vaginally administered IMN does not play a role in promoting delivery in term pregnancy if given at the same time as dinoprostone. This might reflect its relaxant effect on the uterine fundus, which may overcome its cervical softening effect.

Hyaluronidase for cervical ripening and induction of labour

BACKGROUND

Dilatation and effacement of the cervix are not only a result of uterine contractions, but are also dependent upon ripening processes within the cervix. The cervix is a fibrous organ composed principally of hyaluronic acid, collagen and proteoglycan. Hyaluronic acid increases markedly after the onset of labour. An increase in the level of hyaluronic acid is associated with an increase in tissue water content. Cervical ripening during labour is characterised by changes of the cervix and an increased water content. Cervical injection of hyaluronidase was postulated to increase cervical ripening. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of hyaluronidase for third trimester cervical ripening or induction of labour in comparison with other methods of induction of labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (January 2006) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials of hyaluronidase for third trimester cervical ripening or labour induction.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. We assessed trial quality. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

One trial, with 168 women participating, was included in the review. When compared with placebo for cervical ripening intracervical injections of hyaluronidase resulted in women receiving significantly fewer caesarean sections (18% versus 49%, relative risk (RR) 0.37, 95% confidence interval (CI) 0.22 to 0.61), less need for oxytocin augmentation (10% versus 47%, RR 0.20, 95% CI 0.10 to 0.41), and increased cervical favourability after 24 hours (60% versus 98%, RR 0.62, 95% CI 0.52 to 0.74). No side-effects for mother or baby were reported in this trial.

AUTHORS' CONCLUSIONS

Intracervical injections of hyaluronidase for cervical ripening appear beneficial. However, this is not common practice. In addition it is an invasive procedure that women may find unacceptable in the presence of less invasive methods.

Oral misoprostol for induction of labour

BACKGROUND

Misoprostol is a synthetic prostaglandin that can be given orally or vaginally. In most countries misoprostol has not been licensed for use in pregnancy, but its unlicensed use is common because misoprostol is cheap, stable at room temperature and effective in causing uterine contractions. Oral use of misoprostol may be convenient, but high doses could cause uterine hyperstimulation and uterine rupture which may be life-threatening for both mother and fetus.

OBJECTIVES

To assess the effectiveness and safety of oral misoprostol used for labour induction in women with a viable fetus in the third trimester of pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (January 2005).

SELECTION CRITERIA

Randomised trials comparing oral misoprostol versus other methods, placebo or no treatment, given to women with a viable fetus for labour induction.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial quality and extracted data, using centrally-designed data sheets.

MAIN RESULTS

Forty-one trials (8606 participants) were included. In four trials comparing oral misoprostol with placebo (474 participants), women using oral misoprostol were less likely to have long labours (relative risk (RR) 0.16, 95% confidence interval (CI) 0.05 to 0.49), needed less oxytocin (RR 0.32, 95% CI 0.24 to 0.43) and had a lower caesarean section rate (RR 0.62, 95% CI 0.40 to 0.96). In nine trials comparing oral misoprostol with vaginal dinoprostone (2627 participants), women given oral misoprostol were less likely to need a caesarean section, but this reduction reached statistical significance only in the subgroup with intact membranes (RR 0.78, 95% CI 0.66 to 0.94). Uterine hyperstimulation was more common after oral misoprostol (RR 1.63, 95% CI 1.09 to 2.44) although this was not associated with any adverse fetal events. Seven trials (1017 participants) compared oral misoprostol with intravenous oxytocin. The only difference between the groups was an increase in meconium-stained liquor in women with ruptured membranes following administration of oral misoprostol (RR 1.72, 95% 1.08 to 2.74). Sixteen trials (3645 participants) compared oral and vaginal misoprostol and found no difference in the primary outcomes. There was less uterine hyperstimulation without fetal heart rate changes in those given oral misoprostol (RR 0.37, 95% 0.23 to 0.59). Oral misoprsotol was associated with increased need for oxytocin augmentation (RR 1.28, 95% 1.11 to 1.48) and more meconium-stained liquor (RR 1.27, 1.01 to 1.60).

AUTHORS' CONCLUSIONS

Oral misoprostol appears to be more effective than placebo and at least as effective as vaginal dinoprostone. However, there remain questions about its safety because of a relatively high rate of uterine hyperstimulation and the lack of appropriate dose ranging studies. In countries where misoprostol remains unlicenced for the induction of labour, many practitioners will prefer the legal protection of using a licenced product like dinoprostone. There is no evidence that misoprostol given orally is inferior to the vaginal route and has lower rates of hyperstimulation. If misoprostol is used orally, the dose should not exceed 50 mcg.

Breast stimulation for cervical ripening and induction of labour

BACKGROUND

Breast stimulation has been suggested as a means of inducing labour. It is a non-medical intervention allowing women greater control over the induction process. This is one of a series of reviews of methods of cervical ripening and labour induction using a standardised methodology.

OBJECTIVES

To determine the effectiveness of breast stimulation for third trimester cervical ripening or induction of labour in comparison with placebo/no intervention or other methods of induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group Trials Register (March 2004) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials of breast stimulation for third trimester cervical ripening or labour induction.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction.

MAIN RESULTS

Six trials (719 women) were included. Analysis of trials comparing breast stimulation with no intervention found a significant reduction in the number of women not in labour at 72 hours (62.7% versus 93.6%, relative risk (RR) 0.67, 95% confidence interval (CI) 0.60 to 0.74). This result was not significant in women with an unfavourable cervix. A major reduction in the rate of postpartum haemorrhage was reported (0.7% versus 6%, RR 0.16, 95% CI 0.03 to 0.87). No significant difference was detected in the caesarean section rate (9% versus 10%, RR 0.90, 95% CI 0.38 to 2.12) or rates of meconium staining. There were no instances of uterine hyperstimulation. Three perinatal deaths were reported (1.8% versus 0%, RR 8.17, 95% CI 0.45 to 147.77). When comparing breast stimulation with oxytocin alone the analysis found no difference in caesarean section rates (28% versus 47%, RR 0.60, 95% CI 0.31 to 1.18). No difference was detected in the number of women not in labour after 72 hours (58.8% versus 25%, RR 2.35, 95% CI 1.00 to 5.54) or rates of meconium staining. There were four perinatal deaths (17.6% versus 5%, RR 3.53, 95% CI 0.40 to 30.88).

AUTHORS' CONCLUSIONS

Breast stimulation appears beneficial in relation to the number of women not in labour after 72 hours, and reduced postpartum haemorrhage rates. Until safety issues have been fully evaluated it should not be used in high-risk women. Further research is required to evaluate its safety, and should seek data on postpartum haemorrhage rates, number of women not in labour at 72 hours and maternal satisfaction.

Factors involved in the inflammatory events of cervical ripening in humans

BACKGROUND

Cervical ripening is an inflammatory reaction. The glucocorticoid receptor (GR) mediates glucocorticoid anti-inflammatory reactions, whereas nuclear factor (NF)kappaB is a key pro-inflammatory transcription factor. Prostaglandins as well as platelet activating factor (PAF) are inflammatory mediators. Inducible nitric oxide synthase (iNOS) regulates the level of nitric oxide (NO) in response to various inflammatory stimuli. We hypothesize that a changed biological response to glucocorticoids could be a mechanism regulating the inflammatory events resulting in cervical ripening.

METHODS

We monitored GR and NFkappaB, prostaglandin synthases cyclooxygenase (COX)-1 and -2, iNOS, as well as the PAF-receptor (PAF-R) in the uterine cervix from term pregnant women (with unripe cervices) before the onset of labor (TP), immediately after parturition (PP), as compared to non-pregnant (NP), using immunohistochemistry and RT-PCR.

RESULTS

The GR protein was detected by immunohistochemistry in the nuclei of stroma and squamous epithelium (SQ). Stromal GR staining was increased in TP as compared to the NP group and decreased again after parturition. GR staining in SQ was decreased after parturition as compared to term. NFkappaB was present in SQ and glandular epithelium (GE), stroma and vascular endothelium. Increased nuclear NFkappaB staining was observed postpartum as compared to term pregnancy in stroma and GE. Stromal immunostaining for COX-1 as well as COX-2 was increased in the TP and PP groups as compared to the NP, and GE displayed an intensely increased COX-2 immunostaining at term and postpartum. Stromal PAF-R immunostaining was highest at term, while it was greatly increased in GE postpartum. No difference in the immunostaining for iNOS was found between the groups. RT-PCR showed a predominance of GRalpha to GRbeta mRNA in cervical tissue. The COX-2 mRNA level was increased in the PP group as compared to the TP group.

CONCLUSIONS

There is a decrease in GR levels in human cervix at parturition. Concomitantly there is an increase of factors such as NFkappaB, PAF-R, COX-1 and COX-2, suggesting that they may participate in the sequence of events leading to the final cervical ripening.

Active induction management of labor for diabetic pregnancies at term; mode of delivery and fetal outcome—a single center experience

OBJECTIVES

To evaluate the mode of delivery in diabetic pregnancies at term following induction of labor with vaginal application of prostaglandin E2 (PGE2), and to identify possible predictors of successful vaginal delivery.

PATIENTS AND METHODS

The study group consisted of 105 women with diabetic pregnancies at term admitted for induction of labor; 84 (80%) had gestational diabetes (GDM) and 21 (20%) type 1 diabetes. Findings were compared with women who underwent elective induction of labor (n=115), and women with normal spontaneous onset of labor (n=510). Women with previous cesarean section (CS) were excluded from both study and control groups.

RESULTS

Maternal age and gravidity were significantly higher in the study group than the control groups (age: 31.4+/-5, 28+/-5.0 and 28.1+/-4.8 years, respectively; gravidity: 3.0+/-1.9, 2.5+/-1.6, and 2.1+/-1.4, respectively; P<0.001 for both) and gestational age and nulliparity rate were significantly lower (gestational age: 38.6+/-1.1, 40.2+/-1.3 and 39.3+/-2.7 weeks, respectively; nulliparity: 34.6, 45.2, 51.6%, respectively; P<0.002 for both). There were no between-group differences in the incidence of oligohydramnios, number of PGE2 applications used, birth weight, rate of non-reassuring fetal heart rate pattern leading to CS, and rate of low 5 min Apgar score (<7). The rate of CS in the study group (18.2%) was significantly higher than in the spontaneous labor group (9%) but similar to the elective induction group (14.8%). On stepwise analysis, only nulliparity (OR 4.56, 95% CI 1.11-18.67, P=0.035) was independently and significantly associated with increased risk of CS. Within the study group (R2=0.257, P=0.002), type 1 diabetes (OR 2.4, 95% CI 1.04-5.51) was independently and significantly associated with increased risk of CS.

CONCLUSION

In diabetic pregnancies, induction of labor at term with vaginal PGE2 is successful in approximately 82% of patients, but yields a significantly higher CS rate compared to uncomplicated pregnancies. Nulliparity and diagnosis of type 1 diabetes are independently and significantly associated with increased risk of CS.

CONDENSATION

In diabetic pregnancies, induction of labor at term is successful in 82% of patients, but yields higher CS rates compared to uncomplicated pregnancies.

Acupuncture for induction of labour

BACKGROUND

This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. The use of complementary therapies is increasing and some women 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. The limited observational studies to date suggest acupuncture for induction of labour appears safe, has no known teratogenic effects, and may be effective. The evidence regarding the clinical effectiveness of this technique is limited.

OBJECTIVES

To determine the effects of acupuncture for third trimester cervical ripening or induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register (February 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), PubMed (1966 to present), CISCOM (1960 to present), EMBASE (1980 to present) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials comparing acupuncture used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction.

MAIN RESULTS

One trial of 56 women was included in the review. Data were not in a form that could be included in the meta-analysis.

REVIEWER'S CONCLUSIONS

There is a need for well-designed randomised controlled trials to evaluate the role of acupuncture to induce labour and for trials to assess clinically meaningful outcomes.

Induction of labour with a favourable cervix and/or pre-labour rupture of membranes

Premature rupture of membranes (PROM) occurs in 8% of term deliveries. In this situation labour induction with prostaglandins, compared with expectant management, results in a reduced risk of chorioamnionitis, neonatal antibiotic therapy, neonatal intensive care (NICU) admission, and increased maternal satisfaction. The use of prostaglandin is associated with an increased rate of diarrhoea and use of analgesia/anaesthesia. Compared with oxytocin, prostaglandin induction results in a lower rate of epidural use and internal fetal heart rate monitoring but a greater risk of chorioamnionitis, nausea, vomiting, more vaginal examinations, neonatal antibiotic therapy, NICU admission and neonatal infection. Women should be informed of the risks and benefits of each method of induction.Misoprostol is gaining increasing interest as an alternative induction agent. It appears to be an effective method of labour induction with term PROM. Further research is needed to identify the preferred dosage, route and interval of administration, and to assess uncommon maternal and neonatal outcomes. There has been limited research on the use of prostaglandins, including misoprostol, for induction of labour with a favourable cervix and intact membranes. Compared with intravenous oxytocin (with and without amniotomy), labour induction using vaginal prostaglandins in women with a favourable cervix (with and without PROM) results in a higher rate of vaginal delivery within 24 hours and increased maternal satisfaction. In women with a favourable cervix, artificial rupture of membranes followed by oral misoprostol has similar time to vaginal delivery compared with artificial rupture of membranes followed by oxytocin. Further research with prostaglandins, including misoprostol, is needed to evaluate other maternal and neonatal outcomes in women being induced with a favourable cervix. No form of prostaglandin induction in women with PROM or favourable cervix has proven clearly superior to oxytocin infusion.

Oestrogens alone or with amniotomy for cervical ripening or induction of labour

BACKGROUND

Studies in sheep showed that there is a pre-labour rise in oestrogen and a decrease in progesterone, both of these changes stimulate prostaglandin production and may help initiate labour. Though oestrogen has been suggested as an effective cervical ripening or induction agent, research in humans have failed to demonstrate a similar physiological mechanism. The use of oestrogen as an induction agent is not currently common practice, as such this systematic review should be regarded as an historical review. This is one of a series of reviews of methods of cervical ripening and labour induction using a standardised methodology.

OBJECTIVES

To determine, from the best available evidence, the effectiveness and safety of oestrogens alone or with amniotomy for third trimester cervical ripening and induction of labour in comparison with other methods of induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: April 2001.

SELECTION CRITERIA

(1) randomised controlled trials comparing oestrogens alone used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A generic strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally.

MAIN RESULTS

When comparing oestrogen with placebo there was no difference between the rate of caesarean section (7.1% versus 10.3%, relative risk (RR) 0.70, 95% confidence interval (CI) 0.30,1.62). There were no differences between rates of uterine hyperstimulation with or without fetal heart rate changes or instrumental vaginal delivery. None of the studies reported the rates of either vaginal delivery not achieved in 24 hours, or cervix unfavourable/unchanged after 12-24 hours. There were insufficient data to make any meaningful conclusions when comparing oestrogen with vaginal PGE2, intracervical PGE2, oxytocin alone or extra amniotic PGF2a, as to whether oestrogen is effective in inducing labour.

REVIEWER'S CONCLUSIONS

There were insufficient data to draw any conclusions regarding the efficacy of oestrogen as an induction agent.

Extra-amniotic prostaglandin for induction of labour

BACKGROUND

This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of extra-amniotic prostaglandin for third trimester cervical ripening or induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Date of last search: December 2000.

SELECTION CRITERIA

(1) clinical trials comparing extra-amniotic prostaglandin used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This has involved a two-stage method of data extraction. The initial data were extracted centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology.

MAIN RESULTS

Oxytocin was used to initiate or augment labour significantly less frequently with extra-amniotic prostaglandins when compared to placebo (relative risk 0.50, 95% confidence interval 0.38-0.66). No other findings were significant in the comparisons that were made for this review including when extra-amniotic prostaglandins were compared with other methods of cervical ripening or induction of labour. Although this could suggest that extra-amniotic prostaglandins are as effective as other agents, the findings are difficult to interpret because they are based on very small numbers and may lack the power to show a real difference.

REVIEWER'S CONCLUSIONS

The studies in this review are limited by their small sample sizes which are in many cases further divided into multiple comparison groups. The analyses resulted in most comparisons showing no significant differences, with wide confidence intervals. Although extra-amniotic prostaglandins may be as effective as other modalities in initiating labour, there is little conclusive information from this review to guide clinical practice. An adequately powered randomised controlled trial would be useful to determine if the use of extra-amniotic prostaglandins would lower the rate of caesarean section. However, in the time since these studies were undertaken the use of extra-amniotic prostaglandins has largely been replaced by other modes of prostaglandin administration.

Homoeopathy for induction of labour

BACKGROUND

This is one of series of reviews of cervical ripening and labour induction using standardised methodology. Homoeopathy involves the use, in dilution, of substances which cause symptoms in their undiluted form. A type of herb, 'caulophyllum' is one type of homoeopathic therapy that has been used to induce labour.

OBJECTIVES

To determine the effects of homoeopathy for third trimester cervical ripening or induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: March 2001.

SELECTION CRITERIA

Randomised controlled trials comparing homeopathy used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

A generic strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally.

MAIN RESULTS

One trial involving 40 women was included in the review. This trial was placebo controlled and double blind, but the quality was not high. Insufficient information was available on the method of randomisation and the study lacked clinically meaningful outcomes. This trial demonstrated no differences in any outcome between the treatment and control group.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to recommend the use of caulophyllum as a method of induction. It is likely that the demand for complementary medicine will continue and women will continue to consult a homoeopath during their pregnancy. Although caulophyllum is a commonly used homoeopathic therapy to induce labour, the treatment strategy used in this trial may not reflect routine practice of homoeopathy. It may be more appropriate to undertake further evaluation of individualised homeopathic therapies for induction of labour in future clinical trials.

Amniotomy alone for induction of labour

BACKGROUND

Amniotomy (deliberate rupture of the membranes) is a simple procedure which can be used alone for induction of labour if the membranes are accessible, thus avoiding the need for pharmacological intervention. However, the time interval from amniotomy to established labour may not be acceptable to clinicians and women, and in a number of cases labour may not ensue. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of amniotomy alone for third trimester labour induction in women with a live fetus.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled trials register and bibliographies of relevant papers.

SELECTION CRITERIA

The criteria for inclusion included the following: (1) clinical trials comparing amniotomy alone for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random or pseudo-random allocation to the treatment or control group; (3) ideally adequate allocation concealment (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into the series of primary reviews arranged by methods of induction of labour. The data from the primary reviews will be incorporated into a series of secondary reviews, arranged by category of woman to reflect clinical scenarios. To avoid duplication of data in the primary reviews, the labour induction methods have been listed in a specific order, from one to 25. Each primary review includes comparisons between one of the methods (from two to 25) with only those methods above it on the list. This review includes comparisons between amniotomy alone (number 5 on the list) with only those methods above it on the list (no treatment / placebo; intravaginal prostaglandins; intracervical prostaglandins; and oxytocin alone).

MAIN RESULTS

Two trials comprising 50 and 260 women respectively were eligible for inclusion in this review. No conclusions could be drawn from comparisons of amniotomy alone versus no intervention, and amniotomy alone versus oxytocin alone (small trial, only one pre-specified outcome reported). No trials compared amniotomy alone with intracervical prostaglandins. One trial compared amniotomy alone with a single dose of vaginal prostaglandins for women with a favourable cervix, and found a significant increase in the need for oxytocin augmentation in the amniotomy alone group (44% versus 15%; RR 2.85, 95% CI 1.82-4.46). This should be viewed with caution as this was the result of a single centre trial. Furthermore, secondary intervention occurred 4 hours after amniotomy, and this time interval may not have been appropriate.

REVIEWER'S CONCLUSIONS

Data is lacking about the value of amniotomy alone for induction of labour. While there are now other modern methods available for induction of labour (pharmacological agents), there remain clinical scenarios where amniotomy alone may be desirable and appropriate, and this method is worthy of further research. This research should include evaluation of the appropriate time interval from amniotomy to secondary intervention, women and caregivers' satisfaction and economic analysis.