Combination of misoprostol and mechanical dilation for induction of labour: a randomized controlled trial

Obesity at term: What to consider? How to deliver?

Obesity presents significant challenges during pregnancy, increasing the risk of complications and adverse outcomes for both mother and baby. With the rising prevalence of obesity among pregnant women, questions arise regarding optimal management, including timing of delivery and choice of delivery mode. Labour induction in obese women may require a combination of mechanical and pharmacological methods due to increased risk of failed induction. Caesarean section in obese women presents unique challenges, requiring comprehensive perioperative planning and specialized care to optimize outcomes. However, specific guidelines tailored to obese patients undergoing caesarean sections are lacking. Postpartum care should include vigilant monitoring for complications. Addressing obesity in pregnancy necessitates a multidisciplinary approach and specialized care to ensure the best outcomes.

Induction of Labour with a Double Balloon Catheter - Comparison of Effectiveness of Six Versus Twelve Hours Insertion Time: a Prospective Case Control Study

Introduction

Induction of labour is a common obstetric procedure to initiate or augment contractions when labour is delayed or uncertain. The double balloon catheter is a safe and effective mechanical method for cervical ripening during induction of labour. This study evaluates the effectiveness of reducing double balloon catheter insertion time from 12 to 6 hours.

Methods

248 women undergoing induction with a double balloon catheter at term were divided into two groups: catheter placed for 12 hours at 8 pm in the first half of 2021 (P12) and catheter placed for 6 hours at 7 am in the second half of 2021 (P6). T-tests, chi-squared tests, and Wilcoxon signed rank test were used for statistical analysis. Primary and secondary endpoints included induction to delivery interval, prostaglandin to delivery interval, mode of delivery, and maternal and neonatal outcomes.

Results

The P6 group had a significantly reduced induction to delivery interval of 558 min (P6: 1348 min, P12: 1906 min, p < 0.01, 95% CI: 376-710) within demographically comparable groups. Multiparous women also showed a significant reduction in prostaglandin to delivery interval of 260 min (P6: 590 min, P12: 850 min, p = 0.038, 95% CI: 9-299). There were no significant differences in mode of delivery, maternal blood loss, or neonatal outcome.

Conclusion

Reducing double balloon catheter placement time from 12 to 6 hours resulted in almost 9 hours less induction to delivery interval without adverse effects on maternal and neonatal outcome.

Sequential use of drugs (prostaglandin e1 after failed trial of PGE2 gel) for induction of labour: Retrospective observational study

With advancements in medicine, the scope of pregnancies have increased. This has subsequently increased the number of inductions and therefore more caesarean sections. We looked at the efficacy and safety of sequential induction with PGE2 gel followed by PGE1 tablets after a period of rest in a retrospective observational study. Women with failed induction of labour with 3 PGE2 gel were re-induced with 25ug vaginal PGE1 tablets, with a maximum of five doses (sequential regimen). Fetomaternal outcome and vaginal delivery rates were compared between the only-PGE2 gel group and the sequential group.There were 296 inductions of labour, of which 41 were included in the sequential group, amongst whom the vaginal delivery rate was 56%. Caesarean delivery rate with only PGE2 gel would have been 32%, but with the addition of PGE1 vaginal tablet (sequential induction), it reduced by >8% (p  =  0.02). Fetomaternal outcomes were comparable in the two groups. We thus conclude that sequential induction with PGE1 tablets is an effective option.

Foley Bulb Added to an Oral Misoprostol Induction Protocol: A Cluster Randomized Trial

OBJECTIVE

To evaluate whether the induction of labor in term gravid women with cervical dilation 2 cm or less and intact membranes by using oral misoprostol preceded by transcervical Foley bulb placement results in a significantly increased vaginal delivery rate compared with the use of oral misoprostol alone.

METHODS

We randomized the induction method by week of admission to labor and delivery, with each week group described as a cluster in a block randomized design. Women with gestational age of 37 weeks or greater, cervical dilation 2 cm or less, intact membranes, and indication for labor induction were included. Study arms were either 100 micrograms of oral misoprostol after transcervical Foley bulb placement or 100 micrograms of oral misoprostol alone. The primary outcome was vaginal delivery with the first induction attempt. Secondary outcomes included time to delivery, clinical chorioamnionitis (maternal temperature of 38°C or greater during labor with or without fundal tenderness, without other identified cause), cesarean delivery indication, and adverse outcomes. We estimated that a sample size of 1,077 per arm was needed to detect a 5% increase in vaginal delivery rate with a type I error of 5% and power of 80%, accounting for interim analysis and cluster size of 30 inductions per week. This was a pragmatic trial, and analysis was by intention-to-treat.

RESULTS

From January 1, 2018, to May 13, 2019, 1,117 women (34 clusters) were assigned to oral misoprostol plus Foley and 1,110 women (34 clusters) to oral misoprostol alone. Demographic characteristics were similar. Vaginal delivery at the first induction occurred in 78% of the misoprostol plus Foley arm and in 77% of the misoprostol arm (relative risk [RR] 1.00; 95% CI 0.96-1.05; adjusted relative risk [aRR], 1.00; 95% CI 0.95-1.05). Clinical chorioamnionitis occurred in 18% of the misoprostol plus Foley arm and in 14% of the misoprostol arm (RR 1.30; 95% CI 1.07-1.58; aRR 1.30; 95% CI 1.08-1.56). There were no differences in neonatal outcomes.

CONCLUSION

Induction of labor in gravid women at term with intact membranes by using oral misoprostol plus Foley bulb did not result in a higher vaginal delivery rate, but it did result in more clinical chorioamnionitis compared with the use of oral misoprostol alone.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03407625.

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

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

Labor induction with misoprostol vaginal insert compared with dinoprostone vaginal insert

INTRODUCTION

Misoprostol vaginal insert could lead to a significant reduction in the time to vaginal delivery, and an increase in the proportion of women achieving vaginal delivery, compared with dinoprostone vaginal insert. We compared the delivery outcomes of misoprostol 200 μg vaginal insert and dinoprostone 10 mg vaginal insert for induction of labor in women with an unfavorable cervix.

MATERIAL AND METHODS

This is a retrospective observational study conducted on a cohort of 220 women with a Bishop score ≤4 admitted for induction of labor at a single institution. Of these, 109 (49.5%) received the misoprostol vaginal insert and 111 (50.5%) received the dinoprostone vaginal insert. The primary outcome was the vaginal delivery rate. Secondary outcomes were time from induction to vaginal delivery, time to any delivery mode, time from induction to the onset of active labor, oxytocin use, uterine tachysystole and need for tocolysis.

RESULTS

The vaginal delivery rate was 88% in the misoprostol insert group, compared with 74% in the dinoprostone insert group (P < 0.007). The average time from drug administration to the beginning of labor was shorter in the misoprostol compared with the dinoprostone group (855 min vs 1740 min, P < 0.0001). Also, the average time from administration to delivery was shorter for women receiving misoprostol compared with dinoprostone (1113 min vs 2150 min, P < 0.0001). The use of misoprostol reduced the need for oxytocin compared with dinoprostone (30.2% vs 43.2%, P = 0.046). Finally, compared with dinoprostone, the misoprostol insert was associated with more uterine tachysystole (38% vs 12%, P < 0.001), but the rate of tachysystole requiring tocolysis was not significantly different between the 2 groups (51.2% vs 46.1%, P = 0.1). Multivariate analysis showed that Bishop score and method of induction, but not maternal body mass index or gestational age at induction, were independently associated with mode of delivery.

CONCLUSIONS

The cesarean section rate was significantly lower in the misoprostol insert group. The use of misoprostol was also associated with reduced time to vaginal delivery and time to onset of active labor and with decreased use of oxytocin. Tachysystole was a frequent complication during induction of labor with the misoprostol insert.

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

Objective

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

Study design

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

Results

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

Conclusion

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

Misoprostol combined with cervical single or double balloon catheters versus misoprostol alone for labor induction of singleton pregnancies: a meta-analysis of randomized trials

Objective: To compare the effect of misoprostol combined with a cervical single or double-balloon catheter versus misoprostol alone for labor induction of singleton pregnancies with an unfavorable cervix.Methods: Systematic review and meta-analysis of randomized controlled trials (RCTs) regarding the comparison of two schemes for labor induction of singleton cephalic pregnancies with a Bishop score ≤7 and no contraindication for vaginal delivery. Six research databases were searched for articles published in all languages up to 10 May 2018 comparing misoprostol (oral or vaginal) in combination with a cervical placed single or double balloon catheter versus misoprostol treatment alone. Random effects models and inverse variance were used for meta-analyses. Summary measures were mean differences (MDs) and risk ratios (RRs) with 95% confidence interval (CI). Risk of bias was evaluated with the Cochrane tool and publication bias was assessed with Begg's and Egger's tests.Results: Fifteen RCTs reported predefined outcomes. Pooled analyses showed that the combined treatment (misoprostol + catheter) was associated with a shorter induction to delivery time interval (MD = -1.99 hours; 95% CI: -3.42, -0.56); in addition to fewer uterine hyperstimulations (RR = 0.39; 95% CI: 0.23, 0.67) and Neonatal Intensive Care Unit (NICU) admissions (RR = 0.75; 95% CI: 0.58, 0.97) as compared to misoprostol alone. There were no significant differences in RRs for tachysystole, chorioamnionitis, cesarean delivery rate, birthweight, and Apgar score at 5 minutes.Conclusion: The combined use of misoprostol and a cervical balloon catheter reduces the intervention to delivery time interval and number of NICU admissions in women induced with an unfavorable cervix.

Challenges and Limitations of Clinical Trials on Labor Induction: A Review of the Literature

Induction of labor is a common obstetric procedure performed in nearly a quarter of all deliveries in the United States. Pharmacological (prostaglandins, oxytocin) and/or mechanical methods (balloon catheters) are commonly used for labor induction; however, there is ongoing debate as to which method is the safest and most effective. This narrative review discusses key limitations of published trials on labor induction, including the lack of well-designed randomized controlled trials directly comparing specific methods of induction, heterogeneous trial populations, and wide variation in the protocols used and outcomes reported. Furthermore, the majority of published trials were underpowered to detect significant differences in the most clinically relevant efficacy and safety outcomes (e.g., cesarean delivery, neonatal mortality). By identifying the limitations of labor induction trials, we hope to highlight the importance of quality published data to better inform guidelines and drive evidence-based treatment decisions.

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

Objective

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

Material and Method

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

Results

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

Conclusion

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Oral misoprostol alone versus oral misoprostol and Foley's catheter for induction of labor: A randomized controlled trial

AIM

The aim of this study was to evaluate the efficacy of oral misoprostol and Foley's catheter versus oral misoprostol alone for induction of labor.

METHODS

This open-label randomized controlled trial included 335 women requiring induction of labor. A total of 166 women were randomly allocated to induction with oral misoprostol alone and 169 women were assigned for induction with Foley's balloon catheter and oral misoprostol using a computer-generated allocation sequence. The primary outcome was rate of failure to achieve vaginal delivery within 24 h of induction.

RESULTS

The proportion of women failing to achieve vaginal delivery within 24 h in the combination group was lower (11.8% vs 28.7%, P = 0.001). When the two groups were stratified according to parity, the difference remained statistically significant only for parous women. The median induction-to-delivery interval (13.0 h vs 19 h, P = 0.000) and the median number of doses of misoprostol used (2 vs 3, P = 0.000) were lower in the combination group. The number of women who delivered vaginally in the combination group was significantly higher (91% vs 79%, P = 0.001). More neonates born to women in the misoprostol group had Apgar scores < 7 and were admitted to the neonatal intensive care unit (P = 0.016 and P = 0.007, respectively).

CONCLUSION

The rate of failure to achieve vaginal delivery within 24 h was lower with Foley's balloon and oral misoprostol as compared to oral misoprostol alone.

Timing of sequential use of double-balloon catheter and oral misoprostol for induction of labor

AIM

The best time to commence cervical ripening with a balloon catheter is unknown. The aim of this study was to evaluate whether application of a balloon catheter in the morning or in the evening is better when sequential prostaglandin application is planned.

METHODS

This multicenter historical cohort study included 415 women with an unfavorable cervix undergoing labor induction at term. Labor was induced with a double-balloon catheter and the sequential use of oral misoprostol if necessary. The balloon catheter was placed in the morning group between 02:00-15:00 and in the evening group between 15:00-02:00. The primary outcome measure was the cesarean section rate. Secondary outcome measures included failed labor induction (no vaginal delivery within 72 h).

RESULTS

The cesarean section rate did not differ between the groups (morning 26.9%, evening 24.3%; P = 0.5553); however, more women in the morning group did not deliver within 72 h (8.8% vs 3.1%; P = 0.0138). In nulliparous women, labor induction failed more often in the morning group (12% vs. 4%, P = 0.043). In parous women, the induction-to-delivery interval was longer in the morning group (1756 vs. 1349 min; P = 0.046), and there were fewer deliveries within 24 h (35% vs. 56%, P = 0.016).

CONCLUSIONS

When sequential use of a double-balloon catheter and oral misoprostol for labor induction is planned, the preferable time for catheter placement is in the evening. This resulted in fewer failed inductions in nulliparous women and a shorter induction-to-delivery interval and more deliveries within 24 h in parous women.

Double-balloon catheter and sequential oral misoprostol versus oral misoprostol alone for induction of labour at term: a retrospective cohort study

OBJECTIVE

To evaluate the efficacy of induction of labour using a double-balloon catheter and, if necessary, sequential oral misoprostol without delay after removal of the catheter, in comparison with oral misoprostol alone.

STUDY DESIGN

This retrospective cohort study included women undergoing induction of labour with oral misoprostol or double-balloon catheter with sequential oral misoprostol in singleton pregnancies at term. The catheter was placed in the evening and removed when there was no onset of labour within 12h. Then oral misoprostol was started within 3h. Primary outcome measure was the caesarean section rate.

RESULTS

There were 13,082 deliveries during the study period with 3466 labour inductions out of which 1032 were eligible and analysed. The caesarean section rate was significantly lower in the double-balloon catheter group (26.1% vs. 17.3, p=0.021). Furthermore, in the combination group, the induction-to-delivery interval was shorter (median values 1144 vs. 1365min, p=0.001) and there were more deliveries within 24h (51.9 vs. 64.7%, p=0.003) and 48h (87.4 vs. 95.8%, p=0.002). When stratifying for parity, there were less caesarean sections in the combination group (37.2% vs. 24.2%, p=0.015) in nulliparous women, too. In both, nulliparous and parous women, the induction-to-delivery interval was shorter (1742 vs. 1400min, 0.005; 1020 vs. 912min, p=0.018). Especially in parous women, the rates of delivery within 24h (62.6% vs. 79.0%, p=0.007) and 48h (88.6% vs. 99.0%, p=0.007) were higher in the combination group.

CONCLUSION

Double-balloon catheter and sequential oral misoprostol without long delay in absent onset of labour after removal of the catheter resulted in less caesarean section and shorter induction-to-delivery interval in comparison with oral misoprostol alone.

Initial clinical experience with a misoprostol vaginal insert in comparison with a dinoprostone insert for inducing labor

OBJECTIVE

Only one phase III trial has been published to date on the efficacy and safety of misoprostol vaginal inserts for inducing labor. The aim of this study was to compare misoprostol inserts with dinoprostone inserts.

STUDY DESIGN

This retrospective cohort study evaluated the reduction in time to vaginal delivery and delivery within 24h, in routine clinical work, in 119 labor inductions using a 200-μg misoprostol vaginal insert (Misodel(®); June-October 2014) in comparison with 124 inductions using a 10-mg dinoprostone insert (Propess(®); December 2013-April 2014).

RESULTS

Vaginal delivery within 24h occurred in 77.3% (n=92) of the misoprostol cohort and 74.2% (n=92) of the dinoprostone cohort (P=0.654). Time from insert application to vaginal delivery (min) was 761.76 (±409.44, cohort M) versus 805.17 (±473.00, cohort D) (P=0.817). Cesarean delivery was performed in 10.1% (n=12) versus 10.5% (n=13) in the misoprostol and dinoprostone cohorts, respectively (P≥0.999). The modified Bishop scores were 2.0 versus 3.0 (P=0.001), mean body mass index (BMI) was 24.72 versus 23.95 (P=0.033), and fetal scalp blood testing was required in 12.6% (n=15) versus 3.2% (n=4; P=0.008). No differences were observed with regard to the rates of transfer to the neonatal unit or any type of fetal acidosis.

CONCLUSIONS

The groups thus had similar results for rates of vaginal delivery within 24h, cesarean delivery and fetal outcomes. The misoprostol group had lower modified Bishop scores, higher BMIs, and a higher rate of fetal scalp blood testing.

The Renaissance of Transcervical Balloon Catheters for Cervical Ripening and Labour Induction

Due to rising rates of labour induction in industrialised countries, safe and effective methods of induction have once again become a focus of interest and research. Prostaglandins are effective for cervical ripening and induction of uterine contractions. They do, however, cause overstimulation of the uterus in up to 20 % of cases, sometimes causing changes in fetal heart rate. Transcervical balloon catheters provide an alternative to prostaglandins for labour induction and have been used for this purpose for almost 50 years. This induction method has experienced a recent renaissance in clinical practice that is reflected in an annually rising number of publications on its use. Balloon catheters allow gentle ripening of the cervix without causing uterine overstimulation. The two catheters available are the Foley catheter (off-label use) and the double balloon catheter, which is licensed for use in induction of labour. Both are as effective as prostaglandins, and do not increase the risk of infection to mother or child. Catheter induction also requires less monitoring compared to prostaglandins resulting in improved patient satisfaction. Balloon catheters provide a useful and promising option to achieve vaginal delivery despite failed prostaglandin induction. Intravenous oxytocin is nevertheless required in up to 85 % of cases for adequate induction/augmentation of contractions. Balloon catheters, vaginal PGE₂ and misoprostol are equally effective in the context of an unripe/unfavourable cervix, the rate of uterine hyperstimulation being significantly lower, and the need for oxytocin significantly higher for catheters. Balloon catheters are increasingly being used in combination or sequentially with oral/vaginal misoprostol, although there is currently inadequate published data on the subject. International guidelines recommend the use of balloon catheters for labour induction with an unripe cervix (also following previous caesarean section) as an alternative to prostaglandins, particularly when these are not available or are contraindicated.

Double-balloon catheter and sequential vaginal prostaglandin E2 versus vaginal prostaglandin E2 alone for induction of labor after previous cesarean section

PURPOSE

To evaluate the efficacy of inducing labor using a double-balloon catheter and vaginal prostaglandin E2 (PGE2) sequentially, in comparison with vaginal PGE2 alone after previous cesarean section.

METHODS

A total of 264 pregnant women with previous cesarean section undergoing labor induction at term were included in this prospective multicentre cohort study. Induction of labor was performed either by vaginal PGE2 gel or double-balloon catheter followed by vaginal PGE2. The primary outcome measure was the cesarean section rate.

RESULTS

The cesarean section rate was 37 % without any statistically significant difference between the two groups (PGE2: n = 41, 37 % vs. balloon catheter/PGE2: n = 41, 42 %; P = 0.438). The median (range) number of applications of PGE2 [2 (1-10) versus 1 (0-8), P < 0.001] and the total amount of PGE2 used in median (range) mg [2 (1-15) vs. 1 (0-14), P = 0.001] was less in the balloon catheter/PGE2 group. Factors significantly increasing risk for cesarean section were "no previous vaginal delivery" (OR 5.391; CI 2.671-10.882) and "no oxytocin augmentation during childbirth" (OR 2.119; CI 1.215-3.695).

CONCLUSIONS

The sequential application of double-balloon catheter and vaginal PGE2 is as effective as the sole use of vaginal PGE2 with less applications and total amount of PGE2.

Induction of Labour: Change of Method and its Effects

Aim: The combination of mechanical and drug procedures for the induction of labour seems to be beneficial. Accordingly, the normal procedure in clinical routine has been changed and induction of labour by means of a balloon catheter has been implemented. The aim of this study was to find out if this procedural change has resulted in a more effective induction of labour. Materials and Method: In this historical cohort study 230 inductions of labour at term in the year 2012 were compared with 291 inductions of labour in the year 2013, all at the University of Erlangen Perinatal Centre. Exclusion criteria were, among others, a multiple pregnancy, a premature rupture of membranes and a prior Caesarean section. In 2012 births were induced solely by use of the drugs dinoprostone and misoprostol, in 2013 not only with misoprostol but also mainly by use of a balloon catheter. The primary target parameter was the rate of failed labour inductions, defined as "no birth within 72 hours". Results: Altogether 521 inductions of labour were analysed. The rate of failed inductions of labour could be reduced by the changes in induction method (first-time mothers: 23 vs. 9 %, p = 0.0059; multiparous women: 10 vs. 1 %, p = 0.0204). Furthermore, the rate of primary Caesarean sections due to failed induction of labour (5.7 vs. 1.4 %, p = 0.0064), that of the observation of green amniotic fluid (first-time mothers: 23 vs. 9 %, p = 0.0059; multiparous women: 10 vs. 1 %, p = 0.0204) and of infantile infections (first-time mothers: 23 vs. 9 %, p = 0.0059; multiparous women: 10 vs. 1 %, p = 0.0204) were all reduced as well. Conclusion: The routine use of a balloon catheter for induction of labour has markedly improved the procedure. There were fewer failed labour inductions and fewer Caesarean sections due to failed induction of labour.

Comparing vaginal misoprostol versus Foley catheter plus vaginal isosorbide mononitrate for labor induction

OBJECTIVE(S)

To compare the effectiveness and safety of intra-cervical Foley catheter combined with intra-vaginal isosorbide mononitrate (IMN) versus intra-vaginal misoprostol for cervical ripening and labor induction in pregnant women with unripe cervices.

METHODS

Open-labeled randomized controlled trial in Cairo university hospital, Cairo, Egypt during 2012-2014. Three hundred and ninety-five pregnant women at term or post-term with an indication for labor induction and unripe cervix were included in the study. The subjects were randomly divided into two groups. Vaginal misoprostol was used in group 1 (n = 197) and intra-cervical Foley catheter plus vaginal IMN in group 2 (n = 198). Our main outcome measure was cesarean section rate.

RESULTS

Among the 395 included patients there were significantly lower duration of induction of labor (p < 0.001) in group 1with lower cesarean section rates [22.8% in group 1versus 33.3% in group 2; RR 0.7 (0.6-0.9), (p = 0.020)]. Whereas the uterine hyperstimulation (p < 0.001) was significantly higher in group 1. There were no significant differences between both groups as regard patients' demographic characteristics.

CONCLUSIONS(S)

Vaginal misoprostol is more effective but less safe than Foley catheter combined with vaginal IMN for induction of labor in term and post-term pregnancy.