Offering women a choice in induction of labour: a prospective cohort study

Patient Perspectives on Outpatient versus Inpatient Cervical Ripening for Induction of Labor

OBJECTIVE

 Our objective was to compare patient perceived control and experience with outpatient versus inpatient cervical ripening.

STUDY DESIGN

 This is a retrospective mixed-methods analysis of a quality improvement initiative focused on the impact to patients of incorporating outpatient cervical ripening into routine practice. Postpartum inpatients who had elected for outpatient cervical ripening (outpatients) and those who met criteria for outpatient cervical ripening but opted for an inpatient setting (inpatients) were invited to participate in the study. Patients completed the Perceived Control in Childbirth Scale, and scores were compared between outpatient and inpatient groups using Mann-Whitney U test. In addition, semistructured questions elicited feedback prior to hospital discharge, and these qualitative data were analyzed using iterative thematic analysis.

RESULTS

 The study population consisted of 36 outpatients and 38 inpatients. The median score on the Perceived Control in Childbirth Scale was 69 for outpatients and 67 for inpatients (p-value = 0.49), out of a maximum score of 72 (representing the highest level of perceived control). Both groups reported similarly high levels of perceived control, regardless of cervical ripening setting. In the qualitative analysis, pain was the most common theme in both groups. Inpatients reported more distress despite access to stronger pain medications. Outpatients utilized a variety of distraction techniques and expressed gratitude for their setting more than inpatients.

CONCLUSION

 Outpatient cervical ripening can be a patient-centered solution to obstetric throughput challenges arising from increased numbers of inductions. Those who underwent outpatient cervical ripening had similar perceived control to those who underwent inpatient cervical ripening, suggesting that individual patient preferences are most important in determining the optimal setting for care. The patients' reported experiences identified focus areas for process improvement efforts and future research, including improving patient education regarding expectations and innovating new pain management strategies for cervical ripening.

KEY POINTS

· Patient experiences must inform patient-centered care.. · Perceived control with cervical ripening was high.. · Pain with cervical ripening was the most cited theme..

Patient experience in prostaglandins-induced cervical ripening: A comparative study using a standardized questionnaire

OBJECTIVE

Cervical ripening for induction of labor is often associated with negative patient experience. The debate over the most effective cervical ripening method persist, with a significant gap in research specifically addressing patient satisfaction. Our study aims to compare patient experience with two induction methods, slow-release intravaginal dinoprostone device and orally administered misoprostol.

METHOD

We conducted a before-and-after comparative study at a university tertiary hospital, including all patients undergoing cervical ripening with a Bishop score of 3 or lower. Our study compared two separate two-month periods, where the methods for cervical ripening differed. The first period employed an intravaginal dinoprostone slow-release device, while the second period used oral misoprostol. The primary outcome was patient experience, assessed using the EXIT questionnaire, a standardized and validated self-reported measure. Secondary outcomes were efficacy and safety outcomes.

RESULTS

A total of 165 patients were included, 81 induced with dinoprostone and 84 induced with misoprostol. The EXIT questionnaire completion rate was 67.9 % (n = 55) in the dinoprostone group and 76.1 % (n = 64) in the misoprostol group (p = 0.23). Patients induced with misoprostol reported higher levels of satisfaction compared to those induced with dinoprostone, which can be attributed to reduced discomfort associated with the induction process (mean satisfaction score 2.26 ± 0.98 versus 2.80 ± 0.85 on a 1 to 5 likert-scale, p-value < 0.01). Adverse effects were reported less frequently with misoprostol compared to dinoprostone (20.2 % vs 48.1 %, p-value < 0.01). Time between cervical ripening and delivery was shorter in the misoprostol group (27.0 ± 10.2 h vs 32.5 ± 10.0, p < 0.01). There were no difference in mode of delivery or other obstetrical and neonatal outcomes.

CONCLUSION

For women undergoing cervical ripening, oral misoprostol appears to be a less invasive method for labor induction, associated with higher levels of satisfaction and reduced discomfort compared to the intravaginal dinoprostone slow-release device.

[Comparison of vaginal prostaglandins with oral misoprostol as a second line of cervical ripening after using a cervical balloon catheter]

OBJECTIVE

To compare vaginal prostaglandins with oral misoprostol as a second line of cervical ripening after using a cervical balloon catheter.

MATERIAL AND METHODS

This is a retrospective monocentric study (Lille, France), according to a "before"/"after" design. The inclusion criteria were a singleton pregnancy, with a fetus in cephalic presentation, a term >37 WA, with a cervix having a Bishop score lower than 6 after a first line of maturation by cervical balloon catheter. Two groups were formed: "before" corresponding to the continuation of maturation by vaginal prostaglandins, from March 2019 to November 2019, and "after": corresponding to the continuation of maturation by oral misoprostol, from June 2020 to December 2020. The primary outcome was vaginal delivery rate.

RESULTS

One hundred women were included in each group. The rate of vaginal delivery was similar between the 2 groups (76% vs 81%, p=0.39), as were the times between the start of induction and the birth and between the start of induction and the transition to birth room. There was no difference in the indication for caesarean section, with in particular an identical rate of caesarean sections for induction failure (p=0.52). Subgroup analysis in obese women showed a significantly higher rate of vaginal delivery in the "after" group (OR=4.17;95% CI [1.02;17.07]).

CONCLUSION

The vaginal delivery rate is similar when using vaginal prostaglandins or oral misoprostol as second line cervical ripening after use of a cervical balloon catheter.

Continuous vs intermittent induction of labor with oxytocin in nulliparous patients: a randomized controlled trial

BACKGROUND

Oxytocin is considered the drug of choice for the induction of labor, although the optimal protocol and infusion duration remain to be determined.

OBJECTIVE

This study aimed to assess whether the duration of oxytocin infusion increases 24-hour delivery rates and affects the length of time-to-delivery and patient's experience.

STUDY DESIGN

A randomized controlled trial was performed at a single tertiary medical center, between January 1, 2020 and June 30, 2022. Nulliparous patients with a singleton pregnancy at a vertex presentation and a Bishop score ≥6 were randomly assigned to receive either continuous (16 hours, with a 4 hours pause in between infusions) or intermittent (8 hours, with a 4 hours pause in between infusions) oxytocin infusion, until delivery. In both groups, infusion was halted when signs of maternal or fetal compromise were observed. Randomization was conducted with a computer randomization sequence generation program. The primary outcome was delivery within 24 hours from the first oxytocin infusion and the secondary outcome included time-to-delivery, mode of delivery, and additional maternal and neonatal outcomes. Seventy-two patients per group were randomized to reach 80% statistical power with a 20% difference in the primary outcome according to previous studies.

RESULTS

A total of 153 patients were randomized, 72 to the continuous oxytocin infusion group and 81 to the intermittent infusion group. The total oxytocin infusion time was similar between the groups. Patients in the continuous arm were more likely to deliver within 24 hours from oxytocin initiation (79.73% vs 62.96%, P<.05), and had a shorter oxytocin-to-delivery time interval, compared with patients receiving intermittent treatment (9.3±3.7 hours vs 21±11.7 hours, P<.001). Furthermore, time from ruptured membranes to delivery was shorter (9.3±3.7 hours vs 21±11.7 hours; P<.0001) and chorioamnionitis was less frequent (9.46% vs 21%; P<.05) in the continuous compared with the intermittent arm. Cesarean delivery rate was 20% in both groups (P=.226). There was no difference in postpartum hemorrhage, or adverse neonatal outcomes between the groups. Patients receiving continuous oxytocin infusion were more satisfied with the birthing experience.

CONCLUSION

Continuous infusion of oxytocin for labor induction in nulliparous patients with a favorable cervix may be superior to intermittent oxytocin infusion, because it shortens time-to-delivery, decreases chorioamnionitis rate, and improves maternal satisfaction, without affecting adverse maternal or neonatal outcomes.

Women satisfaction on choosing the cervical ripening method: Oral misoprostol versus balloon catheter

Objective

Induction of labor concerns about 29 % of women in Unites States and 33 % in Europe. Among the various methods for cervical ripening, the efficacy and safety profiles of oral misoprostol and balloon catheter are comparable, but data in the literature on maternal satisfaction during induction of labor are few. The objective of this study was to assess the satisfaction of women who chose the method of cervical ripening, i.e. either balloon catheter or oral misoprostol, for induction of labor.

Study design

This retrospective study asked women who had undergone induction of labor between February 1, 2020 and February 28, 2021. After receiving verbal and written information, the choice of method between oral misoprostol and balloon catheter was left to the patient's free appreciation. Satisfaction was assessed by means of a questionnaire distributed to all women during their stay in the maternity unit. The principal assessment criterion was based on women' inclination to choose the same cervical ripening method if induction of labor were to prove necessary in a future pregnancy, and their willingness to recommend this method to a friend. Univariate analyses were conducted using Student's t-test, Chi-2 test or Fisher's exact test.

Results

On 575 women eligible for analysis, 365 (63.5 %) of these women replied to the satisfaction questionnaire. Of this number, 236 (64.7 %) chose cervical ripening by balloon catheter, and 129 (35.3 %) by oral misoprostol. No significant difference was found between the two groups: 68.2 % of women in the balloon catheter group would opt for the same method of cervical ripening if it proved necessary in a future pregnancy and 64.7% would recommend it to a pregnant friend, versus 65.9 % and 63.6 % in the oral misoprostol group, respectively. Women were overall pleased to be able to choose their method of cervical ripening: 90.5 % of patients in the balloon catheter group and 95.3 % in the oral misoprostol group.

Conclusions

When women choose the method of cervical ripening, satisfaction is overall good, irrespective of the method, whether by balloon catheter or misoprostol.

Factors of Non-Compliance with a Protocol for Oral Administration of Misoprostol (Angusta®) 25 Micrograms to Induce Labor: An Observational Study

We set out to identify factors of non-compliance with a protocol for the oral administration of misoprostol 25 µg (Angusta^®) every 2 h (up to eight tablets), for the induction of labor (IOL). We conducted a retrospective study on IOL at term, on singleton pregnancies from 2019 to 2021, in a university hospital. The study included 195 patients, comprising 144 compliant protocols. Pain was statistically more frequent in the non-compliance group (92.2% vs. 62.5%, p < 0.001), and when a midwife was unavailable (15.7% vs. 0.7%, p < 0.001). A multivariable analysis found factors of good response (defined as going into labor before the administration of the median number of tablets, i.e., six) to be an indication for PROM (OR: 12.03, 95% CI: 5.42-26.71), and gestational age at induction (OR: 1.54, 95% CI: 1.19-2.01), independently of BMI, initial Bishop score, and parity. Patients with pain who were able to follow the protocol delivered 9 h earlier than patients with pain who interrupted the protocol and 16 h earlier than patients who experienced no pain. We identified two key elements that favored compliance: (i) providing the next tablet in advance; and (ii) offering patients early epidural analgesia when in pain in order to continue the protocol and go into labor promptly.