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

Factors associated with successful balloon catheter labor induction in women with a previous caesarean section: A retrospective single-center evaluation

BACKGROUND

Labor induction of women with a history of uterine scarring is an increasingly frequent situation and one for which there are currently no clear professional recommendations favoring one method over another. The objectives of this study were to determine the success rate of balloon catheter induction in women with a history of caesarean section and to evaluate the main factors associated with vaginal delivery.

MATERIALS AND METHODS

This single-center retrospective study was conducted between January 1, 2014, and December 31, 2018, in Lille, France, and included all women with one previous caesarean section who were induced by first-line balloon catheter induction. Multivariate analysis was performed to identify the factors associated with the primary outcome (vaginal delivery).

RESULTS

Of the 310 women in the sample, 192 delivered vaginally (62 %). After adjustment, factors associated with successful induction (vaginal delivery) were the number of previous vaginal deliveries (odds ratio [OR] 1.37; 95 % confidence interval [CI] 1.04-1.81), evolution of the Bishop score after balloon removal (OR 1.24; 95 % CI 1.10-1.41), and the initial Bishop score (OR 1.17; 95 % CI 1.00-1.37). Uterine rupture was observed in three women (1 %).

CONCLUSION

The vaginal delivery rate after balloon catheter induction in women with a previous caesarean section was 62 %. Prognostic factors for vaginal delivery include previous vaginal delivery, the initial Bishop score, and evolution of the Bishop score after balloon catheter induction.

Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review

The decision to pursue a trial of labor after cesarean delivery is complex and depends on patient preference, the likelihood of successful vaginal birth after cesarean delivery, assessment of the risks vs benefits of trial of labor after cesarean delivery, and available resources to support safe trial of labor after cesarean delivery at the planned birthing center. The most feared complication of trial of labor after cesarean delivery is uterine rupture, which can have catastrophic consequences, including substantial maternal and perinatal morbidity and mortality. Although the absolute risk of uterine rupture is low, several clinical, historical, obstetrical, and intrapartum factors have been associated with increased risk. It is therefore critical for clinicians managing patients during trial of labor after cesarean delivery to be aware of these risk factors to appropriately select candidates for trial of labor after cesarean delivery and maximize the safety and benefits while minimizing the risks. Caution is advised when considering labor augmentation and induction in patients with a previous cesarean delivery. With established hospital safety protocols that dictate close maternal and fetal monitoring, avoidance of prostaglandins, and careful titration of oxytocin infusion when induction agents are needed, spontaneous and induced trial of labor after cesarean delivery are safe and should be offered to most patients with 1 previous low transverse, low vertical, or unknown uterine incision after appropriate evaluation, counseling, planning, and shared decision-making. Future research should focus on clarifying true risk factors and identifying the optimal approach to intrapartum and induction management, tools for antenatal prediction, and strategies for prevention of uterine rupture during trial of labor after cesarean delivery. A better understanding will facilitate patient counseling, support efforts to improve trial of labor after cesarean delivery and vaginal birth after cesarean delivery rates, and reduce the morbidity and mortality associated with uterine rupture during trial of labor after cesarean delivery.

Retrospective evaluation of labor induction with scar uterus at the university hospital of Rennes

OBJECTIVE

The aim of the study was a retrospective evaluation of labor induction in women with one previous cesarean section. The primary outcome was the mode of delivery. We also studied the severe maternal and neonatal morbidity and identify some prediction factors of vaginal delivery after labor induction after one previous cesarean section.

STUDY DESIGN

This was a retrospective observational monocentric study performed over the period from January 1st, 2016 to April 30th, 2020 at the university hospital of Rennes. Were included women with scar uterus because of one previous cesarean section with a viable singleton fetus in cephalic presentation and an induction of labor for medical reason, at term. Multivariate logistic regression analysis was used to analyze prediction of vaginal delivery after labor induction after one previous cesarean section. We also studied maternal (included uterine rupture, loss of blood, obstetrical injury of anus sphincter) and neonatal (APGAR score, arterial umbilical pH after 1 minute of life and eventual admission to neonatal unit) morbidity. We used a stepwise multivariate logistic regression model to select variables for multivariate analysis. The model with the lowest Akaike Index Criteria was chosen.

RESULTS

The study enrolled 353 women with scar uterus: 121 women were induced by balloon catheter, 57 by osmotic cervical dilatators, 91 by oxytocin alone, 84 by amniotomy. Vaginal delivery rate was 47,9%. There was 45% of vaginal delivery in the group with Bishop < 6 before induction of labor versus 62% in the group with Bishop ≥ 6. There was no statistically significative difference in neonatal and maternal severe morbidities between vaginal delivery and cesarean section: 4,5% of severe maternal morbidities (n = 16). Among their, we highlighted 7 uterine ruptures (3,8%). We observed also 3% of postpartum severe hemorrhage in vaginal delivery group (n = 5) against 1,6% in cesarian section group (n = 3) with no statistical significant difference (p = 0,632). Regarding to the obstetric perineal tears and lacerations we noticed 1,2% of OASIS 3 (n = 2) and 0,6% of OASIS 4 (n = 1). Severe neonatal morbidities were comparable by mode of delivery without significant difference: APGAR score at 5 min was similar (p = 1), as well as arterial umbilical pH after 1 min. (p = 0.719) and admissions to a neonatal unit (p = 1). Two variables were statistically associated with vaginal delivery after labor induction in women with scar uterus: Bishop score ≥ 6 (OR = 0,44; 95%CI: 0,25-0,81) and/or previous vaginal delivery after cesarean section (OR = 0,17; 95%CI: 0,08-0,35).

CONCLUSION

With 47,9% of vaginal delivery after labor induction in women with scar uterus, only 3.8% (n = 7/353) of uterine ruptures, less than 1% APGAR < 7 at 5 min (n = 3/353), induction on scar uterus should be consider in obstetrical practice. Bishop score ≥ 6 and/or previous vaginal delivery after cesarean section are associated to vaginal delivery after labor induction.

Predictors of vaginal delivery following balloon catheter for labor induction in women with one previous cesarean

BACKGROUND

The aim of this study was to estimate predictors for vaginal birth following balloon catheter induction of labor (IOL) in women with one previous cesarean section (CS) and an unfavorable cervix.

METHODS

This 4-year retrospective cohort study was conducted in Longhua District Central Hospital in Shenzhen China, between January 2015 and December 2018. Patients with one previous CS and a current singleton-term pregnancy who underwent balloon catheter cervical ripening and IOL were enrolled. Univariate analysis was used to identify predictive factors associated with vaginal birth after cesarean section (VBAC). Binary logistic regression was further used to identify which factors were independently associated with the outcome measure. The primary outcome was VBAC, which was a successful trial of labor after cesarean delivery (TOLAC) following IOL.

RESULTS

A total of 69.57% (208/299) of the women who planned for IOL had VBAC. In the final binary logistic regression equation, lower fetal weight (< 4000 g) (odds ratio [OR]5.26; 95% confidence interval [CI] 2.09,13.27), lower body mass index (BMI,<30 kg/m²) (OR 2.27; CI 1.21, 4.26), Bishop score after cervical ripening > 6 (OR 1.94; CI 1.37, 2.76) remained independently associated with an increased chance of VBAC.

CONCLUSIONS

The influencing factors of VBAC following IOL were fetal weight, BMI, and Bishop score after cervical ripening. Adequate individualized management and assessment of the IOL may help improve the VBAC rate.

Achieving an appropriate cesarean birth (CB) rate and analyzing the changes using the Robson Ten-Group Classification System (TGCS): Lessons from a Tertiary Care Hospital in Italy

BACKGROUND

To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes.

STUDY DESIGN

An analysis of the contemporaneously collected data from all deliveries that occurred from 2014 to 2018. Major obstetric and neonatal outcomes were analyzed and grouped according to the Ten-Group Classification System (TGCS).

RESULTS

A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported.

CONCLUSIONS

A reduction in CB rate may be safely achieved through implementing a multifaceted strategy.

Comparison of the effectiveness and pregnancy outcomes of labor induction with dinoprostone or single-balloon catheter in term nulliparous women with borderline oligohydramnios

BACKGROUNDS

At present, there is no consensus on the induction methods in term pregnancy with borderline oligohydramnios. This study aimed to compare the effectiveness and pregnancy outcomes of labor induction with dinoprostone or single-balloon catheter (SBC) in term nulliparous women with borderline oligohydramnios.

METHODS

We conducted a retrospective cohort study from January 2016 to November 2018. During the study period, a total of 244 cases were enrolled. Of these, 103 cases were selected for induction using dinoprostone and 141 cases were selected for induction with SBC. The pregnancy outcomes between the two groups were compared. Primary outcomes were successful vaginal delivery rates. Secondary outcomes were maternal and neonatal adverse events. Multivariate logistic regression was used to assess the risk factors for vaginal delivery failure in the two groups.

RESULTS

The successful vaginal delivery rates were similar between the dinoprostone group and the SBC group (64.1% [66/103] vs. 59.6%, [84/141] P = 0.475), even after adjustment for potential confounding factors (adjusted odds ratio [aOR]: 1.07, 95% confidence interval [CI]: 0.57-2.00, P = 0.835). The incidence of intra-amniotic infection was lower in the dinoprostone group than in the SBC group (1.9% [2/103] vs. 7.8%, [11/141] P < 0.001), but the presence of non-reassuring fetal heart rate was higher in the dinoprostone group than in the SBC group (12.6% [13/103] vs. 0.7%, [1/141] P < 0.001). Multivariate logistic regression showed that nuchal cord was a risk factor for vaginal delivery failure after induction with dinoprostone (aOR: 6.71, 95% CI: 1.96-22.95). There were three factors related to vaginal delivery failure after induction with SBC, namely gestational age (aOR: 1.51, 95% CI: 1.07-2.14), body mass index (BMI) >30 kg/m2 (aOR: 2.98, 95% CI: 1.10-8.02), and fetal weight >3500 g (aOR: 2.49, 95% CI: 1.12-5.50).

CONCLUSIONS

Term nulliparous women with borderline oligohydramnios have similar successful vaginal delivery rates after induction with dinoprostone or SBC, with their advantages and disadvantages. In women with nuchal cord, the risk of vaginal delivery failure is increased if dinoprostone is used in the induction of labor. BMI >30 kg/m2, large gestational age, and estimated fetal weight >3500 g are risk factors for vaginal delivery failure after induction with SBC.

Mechanical Methods for the Induction of Labour After Previous Caesarean Section – An Updated, Evidence-based Review

There are currently no up-to-date evidence-based recommendations on the preferred method to induce labour after previous Caesarean section, especially for patients with unripe cervix, as randomised controlled studies are lacking. Intravenous oxytocin and misoprostol are contraindicated in these women because of the high risk of uterine rupture. In women with ripe cervix (Bishop Score > 6), intravenous administration of oxytocin is an effective procedure with comparable rates of uterine rupture to those with spontaneous onset of labour. Vaginal prostaglandin E ₂ (PGE ₂ ) and mechanical methods (balloon catheters, hygroscopic cervical dilators) are effective methods to induce labour in pregnant women with unripe cervix and previous Caesarean section. According to current guidelines, the administration of PGE ₂ is associated with a higher rate of uterine rupture compared to balloon catheters. Balloon catheters are therefore a suitable alternative to PGE ₂ to induce labour after previous Caesarean section, even though this is an off-label use. In addition to two meta-analyses published in 2016, 12 mostly retrospective cohort/observational studies with low to moderate levels of evidence have been published on mechanical methods of cervical ripening after previous Caesarean section. But because of the significant heterogeneity of the studies, substantial differences in study design, and insufficient numbers of pregnant women included in the studies, it is not possible to make any evidence-based recommendations based on these studies. According to a recent meta-analysis, the average rate using balloon catheters is approximately 53% and the average rate after spontaneous onset of labour is 72%. The uterine rupture rate was 0.2–0.9% for vaginal PGE ₂ and 0.56–0.94% for balloon catheters and is therefore comparable to the uterine rupture rate associated with spontaneous onset of labour. According to the product informations, hygroscopic cervical dilators (Dilapan-S) are currently the only method which is not contraindicated for cervical ripening/induction of labour in women with previous Caesarean section, although data are insufficient. Well-designed, randomised, controlled studies with sufficient case numbers comparing balloon catheters and hygroscopic cervical dilators with mechanical methods and vaginal prostaglandin E ₂ /oral misoprostol are therefore necessary to allow proper decision-making.

Induction of labour in patients with prior caesarean births or uterine surgery

The current evidence favours trial of labour after one caesarean in the absence of any other contraindications, recognizing that risks with both trial of labour after caesarean (TOLAC) and elective repeat caesarean section (ERCS) birth are relatively uncommon. When the need for induction of labour (IOL) following a previous caesarean arises, shared decision-making should be based on the current available evidence. This approach, however, needs to be tailored, taking into account the individual's history, initial examination and response to the ongoing process of induction to optimize the maternal and foetal outcomes. This paper aims to review the evidence and provide guidance on decision making surrounding labour induction in a pregnancy following a prior caesarean or uterine surgery.

Induction of labour in mid-trimester pregnancy using double-balloon catheter placement within 12 h versus within 12-24 h

Background

This study aims to evaluate the efficacy and safety of the induction of labour in mid-trimester pregnancy using a double-balloon catheter (DBC) within 12 h versus within 12–24 h.

Methods

In this retrospective study, a total of 58 pregnant women at 14 + 0 weeks to 27 + 6 weeks of gestation were enrolled as research subjects, and they underwent the intended termination of pregnancy at our birth centre from January 1, 2017, to June 31, 2019. Based on the duration of DBC, the patients were divided into two groups, namely, the DBC group within 12 h and the DBC group within 12–24 h.

Results

All 58 cases were successful vaginal deliveries, and no one chose to undergo caesarean section. The success rate of induction (successful abortion of the foetus and placenta without the implementation of dilation and evacuation) was higher in the DBC group within 12–24 h (96.3%, 29/31) than in the DBC group within 12 h (71.0%, 18/27) (p < 0.05). Additionally, the time from DBC removal to delivery in the DBC group within 12–24 h was significantly shorter than that in the DBC group within 12 h (3.0 h versus 17.8 h) (p < 0.05), and the degree of cervical dilation after DBC removal in the DBC group within 12–24 h was larger than that in the DBC group within 12 h (p < 0.05).

Conclusion

In the clinic, the placement time of DBC generally lasts for approximately 12 h. However, considering that the cervical condition is immature in the mid-trimester, properly extending the placement time of DBC to 24 h will benefit cervical ripening and reduce the chance of dilation and evacuation.

Sonographic cervical length predicts vaginal delivery after previous cesarean section in women with low Bishop score induced with a double-balloon catheter

OBJECTIVE

To assess the role of cervical length when predicting vaginal delivery after a previous cesarean section (CS) in women with low Bishop score following the use of a double-balloon catheter for induction of labor (IOL).

METHODS

A prospective, longitudinal study was conducted at a large teaching hospital in Santiago to recruit pregnant women at term with a previous CS and Bishop score ≤6 for IOL with a double-balloon catheter. The device was maintained for up to 24 h and the patient continued IOL with oxytocin only if the Bishop score was >6. Demographic and clinical variables were recorded and compared against vaginal delivery as the primary outcome. Multivariate logistic regression analysis was used to compare perinatal demographic and clinical variables in women achieving vaginal delivery versus those having a repeat CS.

RESULTS

The final cohort included 40 pregnant women. Women achieving vaginal delivery (n = 17, 42.5%) had statistically significant differences in mean cervical length (24.8 mm versus 33.4 mm, respectively; p = .006), median Bishop score after removing the double-balloon catheter (11 versus 7, respectively; p = .005), and mean interval between double-balloon catheter placement and vaginal delivery or the decision to perform a CS (17.4 h versus 23.6 h, respectively; p = .03). Backward stepwise selection revealed an odds ratio of 0.90 (95% confidence interval = 0.82-0.98) for cervical length and a receiver operating characteristic curve area of 0.73.

CONCLUSION

Cervical length, as determined by transvaginal sonography, proved to be effective in predicting vaginal delivery in women with a previous CS and low Bishop score following the use of a double-balloon catheter for IOL.

Factors associated with successful vaginal birth after a cesarean section: a systematic review and meta-analysis

BACKGROUND

Evidence for the relationship between maternal and perinatal factors and the success of vaginal birth after cesarean section (VBAC) is conflicting. We aimed to systematically analyze published data on maternal and fetal factors for successful VBAC.

METHODS

A comprehensive search of Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature, from each database's inception to March 16, 2018. Observational studies, identifying women with a trial of labor after one previous low-transverse cesarean section were included. Two reviewers independently abstracted the data. Meta-analysis was performed using the random-effects model. Risk of bias was assessed by the Newcastle-Ottawa Scale.

RESULTS

We included 94 eligible observational studies (239,006 pregnant women with 163,502 VBAC). Factors were associated with successful VBAC with the following odds ratios (OR;95%CI): age (0.92;0.86-0.98), obesity (0.50;0.39-0.64), diabetes (0.50;0.42-0.60), hypertensive disorders complicating pregnancy (HDCP) (0.54;0.44-0.67), Bishop score (3.77;2.17-6.53), labor induction (0.58;0.50-0.67), macrosomia (0.56;0.50-0.64), white race (1.39;1.26-1.54), previous vaginal birth before cesarean section (3.14;2.62-3.77), previous VBAC (4.71;4.33-5.12), the indications for the previous cesarean section (cephalopelvic disproportion (0.54;0.36-0.80), dystocia or failure to progress (0.54;0.41-0.70), failed induction (0.56;0.37-0.85), and fetal malpresentation (1.66;1.38-2.01)). Adjusted ORs were similar.

CONCLUSIONS

Diabetes, HDCP, Bishop score, labor induction, macrosomia, age, obesity, previous vaginal birth, and the indications for the previous CS should be considered as the factors affecting the success of VBAC.

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

Objective

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

Study design

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

Results

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

Conclusions

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

Clinical analysis of uterine artery embolization combined with double balloon catheter plus curettage for patients with placenta previa who underwent pregnancy termination and suffered antenatal massive hemorrhage in the 2nd trimester: Three case reports

RATIONALE

It is very difficult to treat patients with placenta previa who underwent pregnancy termination and suffered antenatal massive hemorrhage in the 2nd trimester.

PATIENT CONCERNS

In this study, case 1 was with fetal malformation of 18-trisomy syndrome at gestation of 19 weeks + 2 days, case 2 was with fetal malformation of 18-trisomy syndrome at gestation of 22 weeks + 1 day, and case 3 was for intrauterine fetal death at gestation of 27 weeks. All the 3 cases were completely placenta previa.

DIAGNOSES

For the 3 patients, completely placenta previa was confirmed by ultrasound examination after hospitalization and underwent pregnancy termination for fetal death or fetal malformation in the 2nd trimester.

INTERVENTIONS

The 3 patients with placenta previa underwent pregnancy termination by mifepristone combined with ethacridine lactate in the 2nd trimester for intrauterine fetal death or fetal malformation from June 2017 to May 2018, and suffered antenatal massive hemorrhage during termination. Uterine artery embolization (UAE) was immediately performed to achieve hemostasis, then double balloon catheter (DBC) was carried out to promote cervical ripen, at last curettage was implemented with the help of ultrasound. After all these procedures, the clinical outcomes were observed.

OUTCOMES

The antenatal bleeding volume of these 3 patients were about 500, 600, and 550 mL. After implementing the combined treatment, all patients completed the abortion. The UAE-DBC time interval and DBC-curettage time interval were 58.4 and 6.0 hours, respectively, for case 1, whereas almost 0 (i.e., immediately) for cases 2 and 3. Case 1 had a fever lasting for 3 days, and the maximum body temperature was up to 39°C after UAE. Moreover, the blood culture was positive for Escherichia coli after curettage in case 1, whereas it was negative in the other 2 cases.

LESSONS

The UAE-DBC-curettage combined treatment is safe and effective for patients with placenta previa who undergo pregnancy termination and suffered massive antenatal hemorrhage in the 2nd trimester. Future studies are needed to advance our observation.

CERVICAL RIPENING BALLOON AS A METHOD OF PREINDUCTION - ONE CENTER STUDY

- Cervical ripening can be promoted in many ways, but mechanical methods are among the oldest. Like all other methods, this one also has its pros and cons. Disadvantages compared to pharmacological methods include some maternal discomfort upon manipulation of the cervix, a theoretical increase in the risk of maternal and neonatal infection from the introduction of a foreign body, potential disruption of a low-lying placenta, and increase in the need of oxytocin induction of labor. The aim of the study was to evaluate the effect of using cervical ripening balloon in preinduction on the mode of delivery. This was a longitudinal, cohort, intervention, non-randomized one center study. Inclusion criteria were term pregnancies with gestational diabetes, oligohydramnios, intrauterine growth restriction, gestational hypertension/preeclampsia and pregnancies after 41 weeks of pregnancy. Preinduction of labor was performed in term pregnancies at Sestre milosrdnice University Hospital Center. Results in the first 150 women having undergone labor preinduction with cervical ripening balloon were included. Two-sided p values <0.05 were considered significant. Statistical analysis was done using SPSS Version 20.0. The study included 150 women; one woman was excluded from further analyses due to conversion of fetal presentation (head to breech). Indications for labor preinduction were as follows: gestational diabetes, oligohydramnios, intrauterine growth restriction, gestational hypertension/preeclampsia and pregnancies after 41 weeks of pregnancy. Women with normal vaginal delivery (96/149) had lower rates of gestational diabetes and oligohydramnios and used epidural analgesia more frequently. Women with dystocia (32/53) had a significantly longer labor duration and higher neonatal birth weight. In multivariate analysis, multiparity, greater cervical dilatation after balloon removal and use of epidural analgesia were associated with a decreased risk of cesarean section, while the presence of gestational diabetes and oligohydramnios was associated with an increased risk of cesarean section. We found this preinduction method safe and efficient, with a potential to increase the rate of vaginal deliveries.

Predictive factors for successful cervical ripening using a double-balloon catheter after previous cesarean delivery

OBJECTIVE

To identify predictors of successful cervical ripening using double-balloon catheter (DBC) for labor induction among women with previous cesarean delivery (PCD) and unfavorable cervix at term.

METHODS

The present prospective observational study was conducted among women who underwent cervical ripening with DBC at a French tertiary care hospital between January 1, 2014, and December 31, 2017. Inclusion criteria were PCD; singleton term fetus; cephalic presentation; and unfavorable cervix (Bishop score <6). Indications for DBC were gestational diabetes mellitus, intrahepatic cholestasis of pregnancy, pre-eclampsia, prolonged pregnancy, fetal growth restriction, or prenatal suspicion of macrosomia. The primary outcome was Bishop score of at least six after DBC removal.

RESULTS

Among the 105 patients included, the initial Bishop score was 2.5 ± 1.5; successful cervical ripening occurred among 74 (70.5%) women; and vaginal delivery occurred among 46 (43.8%). The mean time from DBC insertion to delivery was 19.3 ± 6.7 hours. No adverse events were observed. Predictors of successful cervical ripening were initial Bishop score of at least three (adjusted odds ratio [aOR] 12.74, 95% confidence interval [CI] 2.78-58.47); PCD during labor (aOR 4.38, 95% CI 1.10-17.45); and internal cervical os open (aOR 4.94, 95% CI 1.44-17.01).

CONCLUSION

Several factors were found to predict successful cervical ripening using DBC.

Mifepristone vs balloon catheter for labor induction in previous cesarean: a randomized controlled trial

OBJECTIVE

To compare oral mifepristone (400 mg) with trans-cervical balloon catheter for induction of labor (IOL) in post date women with previous one cesarean section (CS).

METHODS

In this randomized trial, post date pregnant women (gestation 40 weeks 5 days), with previous one low segment CS (no previous vaginal delivery) were induced either with oral mifepristone (400 mg) or balloon catheter [Foley's catheter (16 Fr); bulb filled with 30 ml normal saline]. They were re-assessed 24 and 48 h later. If at any time Bishop Score was >6; amniotomy was done, followed by oxytocin infusion. Primary outcome of the study was labor onset after first manoeuvre. Secondary outcomes were cervical ripening, need of oxytocin, vaginal delivery and CS, in two groups.

RESULTS

From June 2012 to September 2015, we enrolled 107 women. Out of these, 57 received oral tablet mifepristone (400 mg) and 50 were inserted with balloon catheter. Labor onset after first manoeuvre was statistically significantly more in mifepristone group (37/57 vs. 13/50, respectively; p value 0.000). Bishop Score after 24 h was better in balloon catheter (p value 0.000). More women with balloon catheter required oxytocin for IOL (37/50 vs. 20/57, respectively; p value 0.000) along with higher dose [840 (320) mU vs 560 (120) mU, respectively, p value 0.000]. Failure of induction was statistically significantly higher in balloon catheter group (8 out of 50 vs. 2 out of 57, respectively, p value 0.043). There was no statistically significant difference in normal delivery or CS in either group (p value 0.242 and 0.331, respectively).

CONCLUSION

Oral mifepristone (400 mg) is associated with statistically significantly higher incidence of labor onset in post date pregnant women with previous one CS, as compared to balloon catheter. Both methods are primarily for cervical ripening and oxytocin should not be delayed in the absence of onset of labor.

CLINICAL TRIAL REGISTRATION

Clinical Trials Registry-India, www.ctri.nic.in , CTRI/2012/05/003634.