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Sanchez-Ramos L, Lin L, Vilchez-Lagos G, Duncan J, Condon N, Wheatley J, Kaunitz AM. Single-balloon catheter with concomitant vaginal misoprostol is the most effective strategy for labor induction: a meta-review with network meta-analysis. Am J Obstet Gynecol 2024; 230:S696-S715. [PMID: 38462253 DOI: 10.1016/j.ajog.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 03/12/2024]
Abstract
OBJECTIVE Several systematic reviews and meta-analyses have been conducted to summarize the evidence for the efficacy of various labor induction agents. However, the most effective agents or strategies have not been conclusively determined. We aimed to perform a meta-review and network meta-analysis of published systematic reviews to determine the efficacy and safety of currently employed pharmacologic, mechanical, and combined methods of labor induction. DATA SOURCES With the assistance of an experienced medical librarian, we performed a systematic search of the literature using PubMed, EMBASE, and the Cochrane Central Register of Control Trials. We systematically searched electronic databases from inception to May 31, 2021. STUDY ELIGIBILITY CRITERIA We considered systematic reviews and meta-analyses of randomized controlled trials comparing different agents or methods for inpatient labor induction. METHODS We conducted a frequentist random-effects network meta-analysis employing data from randomized controlled trials of published systematic reviews. We performed direct pairwise meta-analyses to compare the efficacy of the various labor induction agents and placebo or no treatment. We performed ranking to determine the best treatment using the surface under the cumulative ranking curve. The main outcomes assessed were cesarean delivery, vaginal delivery within 24 hours, operative vaginal delivery, hyperstimulation, neonatal intensive care unit admissions, and Apgar scores of <7 at 5 minutes of birth. RESULTS We included 11 systematic reviews and extracted data from 207 randomized controlled trials with a total of 40,854 participants. When assessing the efficacy of all agents and methods, the combination of a single-balloon catheter with misoprostol was the most effective in reducing the odds of cesarean delivery and vaginal birth >24 hours (surface under the cumulative ranking curve of 0.9 for each). Among the pharmacologic agents, low-dose vaginal misoprostol was the most effective in reducing the odds of cesarean delivery, whereas high-dose vaginal misoprostol was the most effective in achieving vaginal delivery within 24 hours (surface under the cumulative ranking curve of 0.9 for each). Single-balloon catheter (surface under the cumulative ranking curve of 0.8) and double-balloon catheter (surface under the cumulative ranking curve of 0.9) were the most effective in reducing the odds of operative vaginal delivery and hyperstimulation. Buccal or sublingual misoprostol (surface under the cumulative ranking curve of 0.9) and the combination of single-balloon catheter and misoprostol (surface under the cumulative ranking curve of 0.9) most effectively reduced the odds of abnormal Apgar scores and neonatal intensive care unit admissions. CONCLUSION The combination of a single-balloon catheter with misoprostol was the most effective method in reducing the odds for cesarean delivery and prolonged time to vaginal delivery. This method was associated with a reduction in admissions to the neonatal intensive care unit.
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Affiliation(s)
- Luis Sanchez-Ramos
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, FL.
| | - Lifeng Lin
- Department of Statistics, Florida State University, Tallahassee, FL
| | | | - Jose Duncan
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - Niamh Condon
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, FL
| | - Jason Wheatley
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, FL
| | - Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, FL
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Sanchez-Ramos L, Levine LD, Sciscione AC, Mozurkewich EL, Ramsey PS, Adair CD, Kaunitz AM, McKinney JA. Methods for the induction of labor: efficacy and safety. Am J Obstet Gynecol 2024; 230:S669-S695. [PMID: 38462252 DOI: 10.1016/j.ajog.2023.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/20/2023] [Accepted: 02/01/2023] [Indexed: 03/12/2024]
Abstract
This review assessed the efficacy and safety of pharmacologic agents (prostaglandins, oxytocin, mifepristone, hyaluronidase, and nitric oxide donors) and mechanical methods (single- and double-balloon catheters, laminaria, membrane stripping, and amniotomy) and those generally considered under the rubric of complementary medicine (castor oil, nipple stimulation, sexual intercourse, herbal medicine, and acupuncture). A substantial body of published reports, including 2 large network meta-analyses, support the safety and efficacy of misoprostol (PGE1) when used for cervical ripening and labor induction. Misoprostol administered vaginally at doses of 50 μg has the highest probability of achieving vaginal delivery within 24 hours. Regardless of dosing, route, and schedule of administration, when used for cervical ripening and labor induction, prostaglandin E2 seems to have similar efficacy in decreasing cesarean delivery rates. Globally, although oxytocin represents the most widely used pharmacologic agent for labor induction, its effectiveness is highly dependent on parity and cervical status. Oxytocin is more effective than expectant management in inducing labor, and the efficacy of oxytocin is enhanced when combined with amniotomy. However, prostaglandins administered vaginally or intracervically are more effective in inducing labor than oxytocin. A single 200-mg oral tablet of mifepristone seems to represent the lowest effective dose for cervical ripening. The bulk of the literature assessing relaxin suggests this agent has limited benefit when used for this indication. Although intracervical injection of hyaluronidase may cause cervical ripening, the need for intracervical administration has limited the use of this agent. Concerning the vaginal administration of nitric oxide donors, including isosorbide mononitrate, isosorbide, nitroglycerin, and sodium nitroprusside, the higher incidence of side effects with these agents has limited their use. A synthetic hygroscopic cervical dilator has been found to be effective for preinduction cervical ripening. Although a pharmacologic agent may be administered after the use of the synthetic hygroscopic dilator, in an attempt to reduce the interval to vaginal delivery, concomitant use of mechanical and pharmacologic methods is being explored. Combining the use of a single-balloon catheter with dinoprostone, misoprostol, or oxytocin enhances the efficacy of these pharmacologic agents in cervical ripening and labor induction. The efficacy of single- and double-balloon catheters in cervical ripening and labor induction seems similar. To date, the combination of misoprostol with an intracervical catheter seems to be the best approach when balancing delivery times with safety. Although complementary methods are occasionally used by patients, given the lack of data documenting their efficacy and safety, these methods are rarely used in hospital settings.
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Affiliation(s)
- Luis Sanchez-Ramos
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, FL.
| | - Lisa D Levine
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
| | - Anthony C Sciscione
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Christiana Hospital, Newark, DE
| | - Ellen L Mozurkewich
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Patrick S Ramsey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center San Antonio, TX
| | - Charles David Adair
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Tennessee College of Medicine, Chattanooga, TN
| | - Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, FL
| | - Jordan A McKinney
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, FL
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Lutgendorf MA, Northup M, Budge J, Snipes M, Overbey J, Taylor A, Simsiman A. Pregnancy outcomes after implementation of an induction of labor care pathway. AJOG GLOBAL REPORTS 2024; 4:100292. [PMID: 38148833 PMCID: PMC10750180 DOI: 10.1016/j.xagr.2023.100292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND Induction of labor is common; however, the optimum clinical strategy for induction of labor is less clear. Variations in clinical practices related to induction of labor may lead to increased complications and longer induction of labor times. OBJECTIVE This study aimed to analyze whether the implementation of an evidence-based standardized care pathway improves the clinical outcomes associated with induction of labor. STUDY DESIGN This was an approved quality improvement project implementing a clinical care pathway for induction of labor. Moreover, this was a retrospective cohort study of inductions of labor for 5 months before (January 2018 to May 2018) and 14 months after (August 2018 to September 2019) the implementation of the care pathway. The primary outcome was time from admission to delivery. Time from admission to delivery was stratified by mode of delivery. The secondary outcomes included chorioamnionitis, endometritis, neonatal intensive care unit admissions, cesarean delivery, postpartum hemorrhage, and a composite of unanticipated outcomes (chorioamnionitis, endometritis, neonatal intensive care unit admissions, cesarean delivery, and postpartum hemorrhage). In addition, pathway adherence was analyzed. The outcomes were analyzed using 2-tailed t tests for continuous data and the Fisher exact test and chi-square tests for categorical data. Propensity score matching was used to assess for confounding by potential covariates. RESULTS A total of 1471 inductions of labor were reviewed, with 392 inductions of labor before the implementation of the care pathway and 1079 inductions of labor after the implementation of the care pathway. The pathway was associated with a nonsignificant reduction in the time from admission to delivery by 1.2 hours (from 23.4 to 22.2 hours; P=.08). There was a nonsignificant increase in the time to cesarean delivery before (28.2 hours) and after (28.8 hours) protocol implementation (P=.71). There was a significant decrease in the time to delivery by 1.7 hours for vaginal deliveries (from 22.2 to 20.5 hours) after protocol implementation (P=.02). There was a significant decrease in chorioamnionitis (from 12.5% to 6.0%; odds ratio, 0.44; 95% confidence interval, 0.29-0.67), a significant decrease in endometritis (from 6.9% to 2.6%; odds ratio, 0.36; 95% confidence interval, 0.20-0.65), and a significant decrease in composite unanticipated outcomes (from 56.9% to 36.6%; odds ratio, 0.46; 95% confidence interval, 0.34-0.56) after the implementation of the care pathway. There was no significant difference in postpartum hemorrhage (from 7.9% to 6.1%; odds ratio, 0.76; 95% confidence interval, 0.48-1.22), neonatal intensive care unit admissions (from 18.1% to 14.0%; odds ratio, 0.74; 95% confidence interval, 0.54-1.02), or cesarean deliveries (from 19.6% to 20.1%; odds ratio, 1.03; 95% confidence interval, 0.76-1.40) after the implementation of the care pathway. Pathway adherence varied, ranging from 50% to 89%. CONCLUSION The introduction of a standardized induction of labor pathway was associated with a nonsignificant reduction in the time from admission to delivery by 1.2 hours and improved pregnancy outcomes, including decreased infections and unanticipated outcomes. Further opportunities for improvements in clinical outcomes may be realized with increased compliance with the care pathway.
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Affiliation(s)
- Monica A. Lutgendorf
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, MD (Dr Lutgendorf)
| | - Megan Northup
- Department of Gynecologic Surgery and Obstetrics, Naval Medical Center San Diego, San Diego, CA (Drs Northup and Simsiman)
| | - Jeffrey Budge
- Office of Clinical Quality Management, Naval Medical Center San Diego, San Diego, CA (Mr Budge)
| | - Marie Snipes
- Department of Mathematics and Statistics, Kenyon College, Gambier, OH (Dr Snipes)
| | - Jamie Overbey
- Department of Pediatrics, Naval Medical Center San Diego, San Diego, CA (Dr Overbey)
| | - Anne Taylor
- Mother Infant Nursing Department, Naval Medical Center San Diego, San Diego, CA (Ms Taylor)
| | - Amanda Simsiman
- Department of Gynecologic Surgery and Obstetrics, Naval Medical Center San Diego, San Diego, CA (Drs Northup and Simsiman)
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Zambrano Guevara LM, Buckheit C, Kuller JA, Gray B, Dotters-Katz S. Evidence Based Management of Labor. Obstet Gynecol Surv 2024; 79:39-53. [PMID: 38306291 DOI: 10.1097/ogx.0000000000001225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
Importance Induction of labor (IOL) is a common obstetric intervention. Augmentation of labor and active management of the second stage is frequently required in obstetric practice. However, techniques around labor and induction management vary widely. Evidence-based practice regarding induction and labor management can reduce birth complications such as infection and hemorrhage and decrease rates of cesarean delivery. Objective To review existing evidence on IOL and labor management strategies with respect to preparing for induction, cervical ripening, induction and augmentation, and second stage of labor techniques. Evidence acquisition Review of recent original research, review articles, and guidelines on IOL using PubMed (2000-2022). Results Preinduction, pelvic floor training and perineal massage reduce postpartum urinary incontinence and perineal trauma, respectively. Timely membrane sweeping (38 weeks) can promote spontaneous labor and prevent postterm inductions. Outpatient Foley bulb placement in low-risk nulliparous patients with planned IOL reduces time to delivery. Inpatient Foley bulb use beyond 6 to 12 hours shows no benefit. When synthetic prostaglandins are indicated, vaginal misoprostol should be preferred. For nulliparous patients and those with obesity, oxytocin should be titrated using a high-dose protocol. Once cervical dilation is complete, pushing should begin immediately. Warm compresses and perineal massage decrease risk of perineal trauma. Conclusion and relevance Several strategies exist to assist in successful IOL and promote vaginal delivery. Evidence-based strategies should be used to improve outcomes and decrease risk of complications and cesarean delivery. Recommendations should be shared across interdisciplinary team members, creating a model that promotes safe patient care.
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Affiliation(s)
- Linda M Zambrano Guevara
- Resident, New York University Langone Health, Department of Obstetrics and Gynecology, New York, NY
| | - Caledonia Buckheit
- Former Resident, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC; Physician, Kamm McKenzie OBGYN, Raleigh, NC
| | | | - Beverly Gray
- Associate Professor, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
| | - Sarah Dotters-Katz
- Associate Professor, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
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Parasiliti M, Vidiri A, Perelli F, Scambia G, Lanzone A, Cavaliere AF. Cesarean section rate: navigating the gap between WHO recommended range and current obstetrical challenges. J Matern Fetal Neonatal Med 2023; 36:2284112. [PMID: 37989541 DOI: 10.1080/14767058.2023.2284112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/13/2023] [Indexed: 11/23/2023]
Abstract
The cesarean section (CS) rate is very heterogeneous all over the world, reflecting the differences in the access to healthcare services. In higher-income countries, changes observed in the obstetrical population brought to an increased rate of cesarean section for maternal request. Besides, clinicians are facing an increasing number of induction of labor, with the consequent risk of CS if the management is inappropriate. Analyzing the rate of primary CS, the interpretation of intrapartum CTG and a tailored management of labor are also red flags that must be considered. In this optic, the implementation of obstetrics training and simulation programs and the improvement of clinical protocols with the latest evidence can lead to the reduction of unnecessary CS.
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Affiliation(s)
- Marco Parasiliti
- Department of Gynecology and Obstetrics, ASST Crema - Ospedale Maggiore, Crema, Italy
| | - Annalisa Vidiri
- Department of Gynecology and Obstetrics, Isola Tiberina Hospital - Gemelli Isola, Rome, Italy
| | - Federica Perelli
- Division of Gynaecology and Obstetrics, Santa Maria Annunziata Hospital, USL Toscana Centro, Florence, Italy
| | - Giovanni Scambia
- Department of Science of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Lanzone
- Department of Science of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Anna Franca Cavaliere
- Department of Gynecology and Obstetrics, Isola Tiberina Hospital - Gemelli Isola, Rome, Italy
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Dasgupta S, Dasgupta J, Goswami B, Mondal J. Randomized controlled trial comparing efficacy of a combination regime containing two cervical sensitizers (mifepristone + Foley's catheter) versus single agent mifepristone or Foley's catheter for labor induction in women attempting TOLAC at late third trimester with a dead fetus in utero. J Obstet Gynaecol Res 2023; 49:2671-2679. [PMID: 37678840 DOI: 10.1111/jog.15772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023]
Abstract
Randomized controlled trial comparing efficacy of a combination regime containing two cervical sensitizers (mifepristone + Foley's catheter) versus single agent mifepristone or Foley's catheter for labor induction in women attempting TOLAC at late third trimester with a dead fetus in utero. AIM To compare efficacy and safety of a new combination regime comprising of two cervical sensitizers used simultaneously with single agents, for labor induction in women attempting TOLAC at ≥34 weeks' gestation with a dead fetus. METHOD This was a multiarm randomized controlled trial (RCT) where participants received one of the three regimes-single agent oral Mifepristone 200 mg, intracervical Foley's catheter (16 Fr size, filled with 40 mL normal saline after intracervical instillation), and combination regime consisting of both used simultaneously. Number of women undergoing vaginal birth within 48 h of induction (VB48 ) was the primary outcome compared between groups. RESULTS VB48 was higher in participants on combination regime in comparison to participants on Foley's catheter (54 vs. 42). Total vaginal births were higher in participants on combination regime compared to both single agents (58 vs. 48 and 44). Duration and dose of oxytocin augmentation was lower in participants on combination regime compared to both single agents. Induction birth interval was short in participants on combination regime compared to those on Foley's catheter. Maternal complications between groups were similar. CONCLUSION Combination of cervical sensitizers for labor induction in late third trimester among women with dead fetus attempting TOLAC resulted in higher proportion of vaginal births and might reduce risk of scar dehiscence due to requirement of a lower dose of oxytocin for augmentation.
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Affiliation(s)
- Subhankar Dasgupta
- Department of Obstetrics and Gynecology, Rampurhat Government Medical College &Hospital, Birbhum, West Bengal, India
| | - Jija Dasgupta
- AILABS, Adani Enterprises LTD, Kolkata, West Bengal, India
| | - Barnali Goswami
- Department of Obstetrics and Gynecology, College of Obstetrics Gynecology and Child Health, CRSS, Kolkata, West Bengal, India
| | - Joyeeta Mondal
- Department of obstetrics and gynecology, Diamond harbor government medical college and hospital, Diamond Harbor, West Bengal, India
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Polónia-Valente R, Costa S, Coimbra C, Xavier J, Figueiredo R, Ferraz T, Machado AP, Moucho M. Labor induction with a combined method (pharmacologic and mechanical): A randomized controlled trial. J Gynecol Obstet Hum Reprod 2023; 52:102649. [PMID: 37611747 DOI: 10.1016/j.jogoh.2023.102649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/04/2023] [Accepted: 08/20/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION The aim of this study was to compare the effectiveness of a combined misoprostol-Foley catheter induction of labor protocol against the current guidelines of our department. MATERIAL AND METHODS A randomized trial was conducted comparing two cervical ripening study groups: combined misoprostol-cervical Foley and the current department practice (misoprostol alone or dinoprostone alone). Women were stratified randomly according to parity for the two intervention groups. The primary outcome was defined as time to delivery (in hours). Secondary outcomes were cesarean delivery rate, time to active labor (defined as dilatation 6 cm or greater), delivery within 12 h, delivery within 24 h, maternal length of stay and indication for cesarean delivery. A composite of maternal morbidity and neonatal morbidity were also analyzed. RESULTS 142 women were randomized into one of the two groups (74 for treatment group and 68 for control group). Demographic and clinical characteristics were similar among the two groups. The primary outcome, the average time to delivery, was faster in the treatment group (22.7 h vs 27.2 h, p = 0.03) and this difference was higher in the nulliparous subgroup (24.2 h vs 29.2 h, p = 0.03). Active phase of labor was achieved faster in the treatment group (17.9 h vs 22.7 h, p = 0.008). The risk for cesarean section was similar in both groups (OR 0.801 (0.527-1.217) vs OR 1.203 (0.871-1.662), p = 0.278). CONCLUSIONS Our study suggests that the combined method of cervical Foley with vaginal misoprostol for women presenting to induction of labor with unfavorable Bishop scores reduces time to delivery safely. The risk for cesarean section was similar in both groups.
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Affiliation(s)
- Rita Polónia-Valente
- Department of Obstetrics, Centro Hospitalar Universitário de São João, Porto, Portugal.
| | - Susana Costa
- Department of Obstetrics, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Carolina Coimbra
- Department of Obstetrics, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Joana Xavier
- Department of Obstetrics, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Rita Figueiredo
- Department of Obstetrics, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Tiago Ferraz
- Faculdade Medicina do Porto, Universidade do Porto (FMUP), Porto, Portugal; Mediclinic Al Murjan Hospital, Jeddah, Saudi Arabia
| | - Ana Paula Machado
- Department of Obstetrics, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Marina Moucho
- Department of Obstetrics, Centro Hospitalar Universitário de São João, Porto, Portugal
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Sharma C, Jaryal S, Soni A. Foley catheter (80 vs 60 mL) and misoprostol for labor induction in nulliparous women: a randomized controlled trial. Am J Obstet Gynecol MFM 2023; 5:101026. [PMID: 37211088 DOI: 10.1016/j.ajogmf.2023.101026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/15/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Induction of labor is a common intervention in obstetrics worldwide. Foley catheter is a commonly used mechanical method for labor induction in nulliparous women with an unfavorable cervix at term. We hypothesize that a higher volume of Foley catheter (80 mL vs 60 mL) will shorten the induction-delivery interval for labor induction in nulliparous women at term with an unfavorable cervix with simultaneous use of vaginal misoprostol. OBJECTIVE This study aimed to evaluate the effect of transcervical Foley catheter (80 mL vs 60 mL) with simultaneous use of vaginal misoprostol on the induction-delivery interval in nulliparous women at term with an unfavorable cervix for induction of labor. STUDY DESIGN In this double-blind, single-center, randomized controlled trial, nulliparous women with a term singleton gestation with unfavorable cervix were randomized to either group 1 (Foley catheter [80 mL] simultaneously with vaginal misoprostol 25 µg every 4h) or group 2 (Foley catheter [60 mL] with vaginal misoprostol 25 µg every 4h). The primary outcome was induction-delivery interval. Secondary outcomes were duration of the latent phase of labor, number of doses of vaginal misoprostol required, mode of delivery, as well as maternal and neonatal morbidity. Analyses were based on the intention-to-treat method. A sample size of 100 women per group (N=200) was selected. RESULTS Between September 2021 to September 2022, 200 nulliparous women at term with an unfavorable cervix were randomized to labor induction with either FC (80 mL vs 60 mL) and vaginal misoprostol. Induction delivery interval (in minutes) was statistically significantly shorter in Foley catheter (80 mL) (median [interquartile range], 604 [524-719] vs 846 [596-990]; [P<.001]). Median time to labor onset (in minutes) (240 [120-300] vs 360 [180-600]; P<.001) was also shorter in group 1 (80 mL). The number of doses of misoprostol required for labor induction was statistically significantly less than with 80 mL (mean±standard deviation, 1.4±0.7 vs 2.4±1.3; P<.001). There was no statistically significant difference in the mode of delivery (vaginal delivery: 69 vs 80; odds ratio, 0.55 [1.1-0.3]; P=.104 and cesarean delivery: 29 vs 17; odds ratio, 0.99 [0.9-1.1]; P=.063, respectively). The relative risk of delivery within 12 hours with 80 mL was 2.4 [95% confidence interval, 1.68-3.43], P<.001. Maternal and neonatal morbidity were similar across the 2 groups. CONCLUSION FC (80 mL) simultaneously with vaginal misoprostol significantly shortens the induction-delivery interval (P<.001) in nulliparous women at term with an unfavorable cervix, as compared with Foley catheter 60 mL and vaginal misoprostol.
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Affiliation(s)
- Chanderdeep Sharma
- Department of Obstetrics & Gynecology, Dr Rajendra Prasad Government Medical College Kangra at Tanda, Kangra, Himachal Pradesh, India.
| | - Sakshi Jaryal
- Department of Obstetrics & Gynecology, Dr Rajendra Prasad Government Medical College Kangra at Tanda, Kangra, Himachal Pradesh, India
| | - Anjali Soni
- Department of Obstetrics & Gynecology, Dr Rajendra Prasad Government Medical College Kangra at Tanda, Kangra, Himachal Pradesh, India
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Elpo JA, Araújo BDA, Volpato LK. Foley catheter plus misoprostol versus misoprostol alone for labor induction. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:119-123. [PMID: 36629651 PMCID: PMC9937608 DOI: 10.1590/1806-9282.20220897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/23/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE This study aimed to analyze the effects of Foley catheter combined with misoprostol in the labor induction process. METHODS This is a nonblinded, block randomized, controlled trial that compared the association between transcervical Foley catheter/vaginal misoprostol 25 μg combination and vaginal misoprostol 25 μg alone in normal-risk and healthy pregnant women undergoing labor induction in the south of Brazil. RESULTS A total of 230 patients with indications for labor induction were evaluated and classified into the "combined" group (Foley catheter plus misoprostol), consisting of 107 patients, and the "misoprostol" group (misoprostol only), consisting of 123 patients. The "combined" group was observed to have a shorter labor induction time (p=0.008). In addition, there was a lower need for misoprostol use for overall cervical ripening (p<0.001) and a lower relative risk of needing a second, third, or fourth misoprostol tablet in the "combined" group (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.71-0.91; RR 0.41; 95%CI 0.31-0.56; and RR 0.29, 95%CI 0.17-0.52, respectively) (p<0.001). No statistically significant difference was found in induction failure rate, cesarean section rate, or perinatal outcomes. CONCLUSION A combination of methods leads to shorter labor induction, lower need for misoprostol doses, and lower risk of cesarean section, with no increase in the rate of perinatal complications. REBEC number is RBR-7xcjz3z.
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Affiliation(s)
- Jhonathan Alcides Elpo
- Hospital Universitário Prof. Polydoro Ernani de São Thiago, Department of Gynecology and Obstetrics – Florianópolis (SC), Brazil
| | - Bruna de Aguiar Araújo
- Hospital Regional de São Jose Dr Homero de Miranda Gomes, Gynecology and Obstetrics Service – São José (SC), Brazil
| | - Lia Karina Volpato
- Hospital Universitário Prof. Polydoro Ernani de São Thiago, Department of Gynecology and Obstetrics – Florianópolis (SC), Brazil.,Hospital Regional de São Jose Dr Homero de Miranda Gomes, Gynecology and Obstetrics Service – São José (SC), Brazil.,Corresponding author:
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Labor induction with combined low-dose oral misoprostol and Foley catheter vs oral misoprostol alone at term gestation—a randomized study. AJOG GLOBAL REPORTS 2022; 2:100060. [PMID: 36276789 PMCID: PMC9563989 DOI: 10.1016/j.xagr.2022.100060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The ideal method for induction of labor is still not clearly defined. Recent reports in literature have shown that oral administration of low-dose misoprostol is as effective as vaginal administration for induction of labor. The use of vaginal misoprostol in combination with Foley catheter has been shown to shorten the period of induction. However, there are limited reports on the use of oral misoprostol in combination with Foley catheter. Given the convenience of oral administration, improved compliance relative to other methods is probable. This study proposed that the combination of oral misoprostol and Foley catheter would be a better means of inducing labor. OBJECTIVE To compare the efficacy of combined low-dose oral misoprostol and Foley catheter with oral misoprostol alone for induction of labor at term gestation. The efficacy was compared in terms of the induction-to-delivery interval and the number of women delivering vaginally within 24 hours. The second objective was to document adverse events, if any, of the 2 protocols. STUDY DESIGN The study was conducted at a tertiary care center and included 200 patients with indication for induction, randomly allotted to either of the 2 groups: group A (a combination of Foley catheter and 25-µg misoprostol every 2 hours orally) and group B (only 25-µg misoprostol every 2 hours orally), using computer-generated random number sequence. The obstetrical and neonatal outcomes were recorded and compared between the 2 groups. Quantitative variables were compared using unpaired and paired t-tests within the groups across follow-ups. RESULTS Group A had significantly shorter mean induction-to-active-labor interval (10.67±1.75 vs 16.28±1.69 hours), mean induction-to-full-dilation interval (11.49 vs 19.00 hours), and mean induction-to-delivery interval (16.85 vs 21.90 hours). The proportion of women delivering vaginally within 24 hours was higher in group A (76 vs 57 women). In comparing maternal side effects, the only significant difference between the 2 groups was found in postpartum hemorrhage. A 5-minute Apgar score <7 was significantly more frequent in group B. CONCLUSION The combination of oral misoprostol with transcervical Foley catheter reduced the induction-to-delivery interval significantly (P=.001). In addition, the proportion of women delivering vaginally within 24 hours was significantly higher. Hence, the use of oral misoprostol with Foley catheter for induction of labor would be beneficial for patients.
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11
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Gulersen M, Zottola C, Li X, Krantz D, DiSturco M, Bornstein E. Chorioamnionitis after premature rupture of membranes in nulliparas undergoing labor induction: prostaglandin E2 vs. oxytocin. J Perinat Med 2021; 49:1058-1063. [PMID: 34109770 DOI: 10.1515/jpm-2021-0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/27/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To assess the risk of chorioamnionitis in nulliparous, term, singleton, vertex (NTSV) pregnancies with premature rupture of membranes (PROM) and an unfavorable cervix undergoing labor induction with either prostaglandin E2 (PGE2) or oxytocin only. METHODS Retrospective cohort of NTSV pregnancies presenting with PROM who underwent labor induction with either PGE2 (n=94) or oxytocin (n=181) between October 2015 and March 2019. The primary outcome of chorioamnionitis was compared between the two groups. Statistical analysis included Chi-squared and Wilcoxon rank-sum tests, as well as logistic regression. For time to delivery, a Cox proportional hazard regression was used to determine the hazard ratio (HR) and adjusted HR (aHR). RESULTS Baseline characteristics were similar between the two groups. Cervical ripening with PGE2 was associated with an increased rate of chorioamnionitis (18.1 vs. 6.1%; aOR 4.14, p=0.001), increased neonatal intensive care unit admissions (20.2 vs. 9.9%; aOR 2.4, p=0.02), longer time interval from PROM to delivery (24.4 vs. 17.9 h; aHR 0.56, p=<0.0001), and lower incidence of meconium (7.4 vs. 14.4%; aOR 0.26, p=0.01), compared to the oxytocin group. CONCLUSIONS Based on our data, the use of oxytocin appears both superior and safer compared to PGE2 in NTSV pregnancies with PROM undergoing labor induction.
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Affiliation(s)
- Moti Gulersen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital - Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Cristina Zottola
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital - Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | | | | | - Mariella DiSturco
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital - Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Eran Bornstein
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital - Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
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12
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Evans MI, Britt DW, Worth J, Mussalli G, Evans SM, Devoe LD. Uterine contraction frequency in the last hour of labor: how many contractions are too many? J Matern Fetal Neonatal Med 2021; 35:8698-8705. [PMID: 34732091 DOI: 10.1080/14767058.2021.1998893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Increased frequency of uterine contractions is a component in the cluster of causal conditions that can lead to fetal hypoxia and acidosis and increase the risk for neonatal neurologic injury. For most international obstetrical societies, 5 contractions per 10 min averaged over 30 min is considered as the upper limit of normal uterine activity. We hypothesize that it might be safer to adopt an upper limit of 4 contractions per 10 min. METHODS We reviewed our 1970's research database containing 475 patients with closely monitored and well-documented labor and neonatal assessments that included cord blood (CB) pH, base excess (BE), and continuous recording of neonatal heart rate (NHR). Using data segregated by the proportion of the last hour before delivery when uterine contraction frequency (UCF) exceeded 4 and 5 contractions per 10 min respectively, we evaluated outcomes (CB BE, pH, Apgar scores at 1 min, the status of NHR at 16 min after birth, and the proportion of births that did not the result from normal spontaneous vaginal deliveries (NSVDs). ANOVA established relationships between UCF cutoffs and these outcomes. Our sample size is sufficiently large to provide the ability of UCF, per se, to accurately detect an alpha region of .05 88% of the time with an effect size of .15. RESULTS During the last hour prior to delivery, a UCF cutoff at 4 contractions per 10 min performed better than a UCF cutoff at 5 contractions per 10 min to enable the earlier identification of risks for abnormal outcomes. The longer UCF was increased, the worse were the outcomes that were measured, and the region >4 but ≤5 contractions identifies the beginnings of worsening conditions in a variety of measures of poor outcomes. CONCLUSION Lowering the recommended threshold for UCF from 5 to 4 contractions per 10-minute period as averaged over 30 min facilitates earlier detection of potentially compromised fetuses and is also an important contributor to a multicomponent contextualized approach to risk assessment.
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Affiliation(s)
- Mark I Evans
- Fetal Medicine Foundation of America, New York, NY, USA.,Comprehensive Genetics, PLLC, New York, NY, USA.,Department of Obstetrics & Gynecology, Icahn School of Medicine at Mt. Sinai, New York, USA
| | - David W Britt
- Fetal Medicine Foundation of America, New York, NY, USA
| | - Jaqueline Worth
- Department of Obstetrics & Gynecology, Icahn School of Medicine at Mt. Sinai, New York, USA
| | - George Mussalli
- Department of Obstetrics & Gynecology, Icahn School of Medicine at Mt. Sinai, New York, USA
| | - Shara M Evans
- Fetal Medicine Foundation of America, New York, NY, USA.,Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lawrence D Devoe
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, GA, USA
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13
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Chow R, Li A, Wu N, Martin M, Wessels JM, Foster WG. Quality appraisal of systematic reviews on methods of labour induction: a systematic review. Arch Gynecol Obstet 2021; 304:1417-1426. [PMID: 34495378 DOI: 10.1007/s00404-021-06228-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/31/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Induction of labour has become more common over the last decade, together with an increase in the number of systematic reviews of the subject. However, with multiple systematic reviews it is necessary to evaluate the methodological rigor to ensure the reliability of conclusions and recommendations for clinical practice. Therefore, the aim of this study was to appraise the quality of systematic reviews that examined the efficacy and/or safety of labour induction methods. METHODS An electronic search of MEDLINE, Embase, and the Cochrane Library from 2000 to 2020 was conducted. Study selection, data extraction and quality assessment were conducted using A Measurement Tool to Assess Systematic Reviews (AMSTAR) by two independent reviewers, in duplicate. RESULTS The search identified 387 publications, of which 48 studies (13%) met the a priori inclusion criteria. No significant relationships were found between study quality and number of citations, journal impact factor, or publication year. CONCLUSION Methodological quality for systematic reviews on the induction of labour were ranked as moderate with no significant changes in quality over the past 2 decades. Publication characteristics are not significantly associated with methodological quality, indicating that healthcare professionals should critically appraise studies before applying them to practice.
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Affiliation(s)
- Ryan Chow
- Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1N 6N5, Canada.,Department of Obstetrics and Gynecology, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Allen Li
- Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1N 6N5, Canada
| | - Nicole Wu
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Morgan Martin
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Jocelyn M Wessels
- Department of Obstetrics and Gynecology, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Warren G Foster
- Department of Obstetrics and Gynecology, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada.
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14
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Induction of labour in low-resource settings. Best Pract Res Clin Obstet Gynaecol 2021; 77:90-109. [PMID: 34509391 DOI: 10.1016/j.bpobgyn.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/23/2022]
Abstract
Due to the disparity in resource availability between low- and high-resource settings, practice recommendations relevant to high-income countries are not always relevant and often need to be adapted to low-resource settings. The adaptation applies to induction of labour (IOL) which is an obstetric procedure that deserves special attention because it involves the initiation of a process that requires regular and frequent monitoring of the mother and foetus by experienced healthcare professionals. Lack of problem recognition and/or substandard care during IOL may result in harm with long-term sequelae. In this article, the authors discuss unique challenges such as insufficient resources (including staff, midwives, doctors, equipment, and medications) that result in occasional inadequate patient monitoring and/or delayed interventions during IOL in low-resource settings. We also discuss modifications in indications and methods for IOL, issues related to human immunodeficiency virus (HIV) infections, the feasibility of outpatient induction, clinical protocols and a minimum dataset for quality improvement projects. Overall, the desire to achieve a vaginal birth with IOL should not cloud the necessity to observe the required safety measures and implement necessary interventions; given that childbirth practices are the major determinants of pregnancy outcomes and patient satisfaction.
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15
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Kehl S, Weiss C, Rath W, Schneider M, Stumpfe F, Faschingbauer F, Beckmann MW, Stelzl P. Labour Induction with Misoprostol in German Obstetric Clinics: What Are the Facts on Such Use? Geburtshilfe Frauenheilkd 2021; 81:955-965. [PMID: 34393259 PMCID: PMC8354357 DOI: 10.1055/a-1538-2200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/25/2021] [Indexed: 11/09/2022] Open
Abstract
Subject While the synthetic prostaglandin E1 analogue misoprostol is the most effect labour induction agent, its use is off-label for the most part. For this reason, and in view of its potential adverse effects and varying approaches to its administration, the drug has recently once again become a focus of critical attention. The objective of this survey was thus to establish a record of labour induction with misoprostol in German clinics and determine the impact of the negative reporting on everyday obstetric practice. Material and Methods In this cross-sectional study, 635 obstetrics and gynaecology departments in Germany were requested by email to participate in our survey in February/March 2020. Online responses to 19 questions were requested regarding the clinic, use of misoprostol before and after the critical reporting, use of misoprostol (sourcing, method of administration, dosage, monitoring) and other labour induction methods. Results A total of 262 (41.3%) of the clinics solicited for the survey completed the questionnaire. There were no differences regarding the care level (Perinatal Centre Level I, Perinatal Centre Level II, Clinic with Perinatal Focus or Obstetric/Private Clinic; p = 0.2104) or birth counts (p = 0.1845). In most cases, misoprostol was prepared in the clinic's own pharmacy (54%) or imported from another country (46%) and administered orally in tablet form (95%). Misoprostol dosage levels varied (25 µg [48%], 50 µg [83%], 75 µg [6%], 100 µg [47%] and > 100 µg [5%]). Most of the clinics used premanufactured tablets/capsules (59%), although Cytotec tablets were also divided (35%) or dissolved in water (5%). Misoprostol administration intervals were mainly every 4 hours (64%) or every 6 hours (30%). CTG checks were run in most cases before and after administration of a dose of misoprostol (78% and 76%) and before and after administration of a dose of prostaglandin E2 (both 88%). Presence of contractions led to no misoprostol (59%) or no prostaglandin E2 (64%) being administered in most cases. The critical reporting resulted in discontinuation of use of misoprostol in 17% of the clinics - mainly smaller obstetric/private clinics with fewer than 1000 births. Labour cocktails were used mainly in obstetric and private clinics (61%). Conclusion Misoprostol is an established agent for labour induction in German clinics. The dosing schemes used vary. Improvements of currently common management practices are required, especially in the area of labour induction (CTG checks before and after administration of labour-inducing medication, no administration of prostaglandin if contractions are ongoing). The discussion of use of misoprostol in the media resulted in stoppage of its use mainly in smaller clinics.
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Affiliation(s)
- Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Christel Weiss
- Abteilung für Medizinische Statistik, Biomathematik und Informationsverarbeitung, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Werner Rath
- Medizinische Fakultät, Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Florian Stumpfe
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | - Patrick Stelzl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
- Abteilung für Gynäkologie, Geburtshilfe und Gynäkologische Endokrinologie, Kepler Universitätsklinikum Linz, Linz, Austria
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16
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Carlson N, Ellis J, Page K, Dunn Amore A, Phillippi J. Review of Evidence-Based Methods for Successful Labor Induction. J Midwifery Womens Health 2021; 66:459-469. [PMID: 33984171 PMCID: PMC8363560 DOI: 10.1111/jmwh.13238] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/20/2021] [Accepted: 03/24/2021] [Indexed: 11/30/2022]
Abstract
Induction of labor is increasingly a common component of the intrapartum care. Knowledge of the current evidence on methods of labor induction is an essential component of shared decision-making to determine which induction method meets an individual's health needs and personal preferences. This article provides a review of the current research evidence on labor induction methods, including cervical ripening techniques, and contraction stimulation techniques. Current evidence about expected duration of labor following induction, use of the Bishop score to guide induction, and guidance on the use of combination methods for labor induction are reviewed.
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Affiliation(s)
- Nicole Carlson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Jessica Ellis
- College of Nursing, University of Utah, Salt Lake City, Utah
| | - Katie Page
- Centra Medical Group Women's Center, Forest, Virginia
| | - Alexis Dunn Amore
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Julia Phillippi
- School of Nursing, Vanderbilt University, Nashville, Tennessee
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17
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Zakama A, Sobhani NC, Lamar R, Rosenstein MG. Implementation of Evidence-Based Cervical Ripening Protocol: Outcomes and Next Steps. AJP Rep 2020; 10:e408-e412. [PMID: 33294286 PMCID: PMC7714617 DOI: 10.1055/s-0040-1721443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/24/2020] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Arthurine Zakama
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California
| | - Nasim C Sobhani
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California
| | - Robyn Lamar
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California
| | - Melissa G Rosenstein
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California
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18
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Berghella V, Bellussi F, Schoen CN. Evidence-based labor management: induction of labor (part 2). Am J Obstet Gynecol MFM 2020; 2:100136. [PMID: 33345875 DOI: 10.1016/j.ajogmf.2020.100136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/25/2020] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
Abstract
Induction of labor is indicated for many obstetrical, maternal, and fetal indications. Induction can be offered for pregnancy at 39 weeks' gestation. No prediction method is considered sensitive or specific enough to determine the incidence of cesarean delivery after induction. A combination of 60- to 80-mL single-balloon Foley catheter for 12 hours and either 25-μg oral misoprostol initially, followed by 25 μg every 2-4 hours, or 50 μg every 4-6 hours (if no more than 3 contractions per 10 minutes or previous uterine surgery), or oxytocin infusion should be recommended for induction of labor. Adding membrane stripping at the beginning of induction should be considered. Once 5-6 cm of cervical dilation is achieved during the induction of labor, consideration can be given to discontinue oxytocin infusion if in use at that time and adequate contractions are present. Induction with oxytocin immediately (as soon as feasible) or up to 12 hours of term prelabor rupture of membranes if labor is not evident is recommended. Outpatient Foley ripening can be considered for low-risk women. Cesarean delivery should not be performed before 15 hours of oxytocin infusion and amniotomy if feasible and ideally after 18-24 hours of oxytocin infusion.
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Affiliation(s)
- Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA.
| | - Federica Bellussi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Corina N Schoen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Massachusetts-Baystate, Springfield, MA
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Comparison of the Cook vaginal cervical ripening balloon with prostaglandin E2 insert for induction of labor in late pregnancy. Arch Gynecol Obstet 2020; 302:579-584. [PMID: 32617665 DOI: 10.1007/s00404-020-05597-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 05/06/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To compare the effectiveness of the Cook vaginal cervical ripening balloon (CCRB) with prostaglandin E2 (PGE2) insert for induction of labor in late pregnancy in primipara. METHODS We evaluated the effectiveness and safety of induction of labor using the improved Bishop score after CCRB or PGE2 administration, total stage of labor, hours until delivery (hours from placement of CCRB or PGE2 insert to parturition and delivery), delivery rate within 24 h, spontaneous delivery rate, successful induction rate, overstimulation syndrome, urgent delivery rate, pain scores, cesarean section rate, and outcomes related to delivery and perinatal morbidity, such as puerperal infection rate, total cost, satisfaction survey, and so on. RESULTS The improved Bishop Score and delivery rate within 24 h in the CCRB group were significantly higher than in the PGE2 group. The total stage of labor and hours until delivery in the CCRB group were significantly shorter than that in the PGE2 group. Rate of overstimulation syndrome and pain scores in the CCRB group were significantly lower than in the PGE2 group. Compared with the PGE2 group, the mean duration of hospitalization in the CCRB group was shorter and the total cost was less. No difference in satisfaction between the PGE2 and CCRB groups was observed. CONCLUSIONS Compared with PGE2, CCRB reduced the total stage of labor, hours until delivery, pain scores, mean length of hospitalization, and total cost. CCRB increased the rate of delivery within 24 h with similar safety and maternal satisfaction compared with PGE2.
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20
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Pekarev OG, Brega ES, Gus AI, Lunkov SS, Dikke GB, Kochev DM, Sukhikh GT. Sonoelastography for the comparative assessment of cervical maturation after different approaches to cervical preparation ahead of labor induction. J Matern Fetal Neonatal Med 2020; 35:1865-1871. [PMID: 32460594 DOI: 10.1080/14767058.2020.1770220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Aim: To compare the efficacy of different approaches to cervical preparation to labor induction using the ultrasound cervical elastography.Materials and methods: This prospective open-label study included 200 pregnant women aged between 23 and 38 years eligible for labor pre-induction. Patients were divided into four groups (n = 50 per group). In Group I, four osmotic Dilapan-S cervical dilators combined with two doses of oral mifepristone (200 mg each) 24 h apart were used. The dilators were inserted for up to 12 h. In Group II, only the Dipalan-S dilators were used. In Group III, a Foley catheter was positioned intracervically for 12 h. In Group IV, we used two doses of intracervical prostaglandin E2 gel (0.5 mg each) 6 h apart. Cervical maturation was assessed using the Bishop scoring system and the ultrasound cervicometry with the color mapping and calculation of SR ratio. At baseline, all participants were also divided into three subgroups depending on the Bishop score before the pre-induction. Subgroup А (n = 66) included patients with the Bishop score between 0‒2 points, subgroup B (n = 69) between 3-4 points, and subgroup С (n = 65) between 4-6 points.Results: Our study showed that the efficacy of Dilapan-S combined with mifepristone for cervical preparation to labor induction was higher than Dilapan-S, Foley catheter and intracervical prostaglandin E2 gel. In this group, the Bishop score after the pre-induction was the highest (11.4 (0.21) points versus 10.2 (0.2), 9.4 (0.3) и 9.67 (0.25) in Groups II, III and IV respectively (p < .05 for all). The lowest SR values were also observed among the patients receiving the combination of Dilapan-S and mifepristone: 1.23 (0.04) versus 1.63 (0.07), 1.7 (0.08) and 1.83 (0.1) in Groups II, III and IV respectively (p < .05 for all). The sonoelastographic SR values in subgroups B and C were statistically lower compared with subgroup A across all groups studied. Ultrasound elastography of the cervix allowed to perform a more objective assessment of cervical maturation compared with the Bishop scoring.Conclusion: Dilapan-S combined with mifepristone had higher efficacy for cervical preparation to labor induction compared with other approaches investigated.
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Affiliation(s)
- O G Pekarev
- "National Medical Research Centre of Obstetrics, Gynaecology and Perinatology named after academician V.I. Kulakov", Ministry of Healthcare of the Russian Ministry of Health, Moscow, Russia
| | - E S Brega
- "National Medical Research Centre of Obstetrics, Gynaecology and Perinatology named after academician V.I. Kulakov", Ministry of Healthcare of the Russian Ministry of Health, Moscow, Russia
| | - A I Gus
- "National Medical Research Centre of Obstetrics, Gynaecology and Perinatology named after academician V.I. Kulakov", Ministry of Healthcare of the Russian Ministry of Health, Moscow, Russia
| | - S S Lunkov
- "National Medical Research Centre of Obstetrics, Gynaecology and Perinatology named after academician V.I. Kulakov", Ministry of Healthcare of the Russian Ministry of Health, Moscow, Russia
| | - G B Dikke
- Medical Education Academy named after I.F. Inozemtsev, Saint Petersburg, Russia
| | | | - G T Sukhikh
- "National Medical Research Centre of Obstetrics, Gynaecology and Perinatology named after academician V.I. Kulakov", Ministry of Healthcare of the Russian Ministry of Health, Moscow, Russia
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Abstract
The rate of labor induction is steadily increasing and, in industrialized countries, approximately one out of four pregnant women has their labor induced. Induction of labor should be considered when the benefits of prompt vaginal delivery outweigh the maternal and/or fetal risks of waiting for the spontaneous onset of labor. However, this procedure is not free of risks, which include an increase in operative vaginal or caesarean delivery and excessive uterine activity with risk of fetal heart rate abnormalities. A search for “Induction of Labor” retrieves more than 18,000 citations from 1844 to the present day. The aim of this review is to summarize the controversies concerning the indications, the methods, and the tools for evaluating the success of the procedure, with an emphasis on the scientific evidence behind each.
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Affiliation(s)
- Anna Maria Marconi
- Department of Health Sciences, San Paolo Hospital Medical School, University of Milano, Milano, Italy
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