Foley Catheter Compared With the Controlled-Release Dinoprostone Insert: A Randomized Controlled Trial

Vaginal dinoprostone vs Foley catheter for induction of labor at term with an unfavorable cervix: an open-label randomized controlled trial

BACKGROUND

Induction of labor (IOL) with mechanical methods or pharmacological agents is used in about 20% to 30% of all pregnant women. We specialized in comparing the effectiveness and safety of dinoprostone vs transcervical Foley catheter for IOL in term pregnant women with an unfavorable cervix with adequate samples.

OBJECTIVE

To compare the effectiveness and safety of dinoprostone vs transcervical Foley catheter for IOL in term pregnant women with an unfavorable cervix.

STUDY DESIGN

This is a parallel, open-label randomized controlled trial in two maternal centers in Shanghai, China between October 2019 and July 2022. Women with a singleton pregnancy in cephalic presentation at term and an unfavorable cervix (Bishop score <6) scheduled for IOL were eligible. A total of 1860 women were randomly allocated to cervical ripening with either a dinoprostone vaginal insert (10 mg) or a 60 cc Foley catheter for up to 24 hours. The primary outcomes were vaginal delivery rate and time to vaginal delivery. Secondary outcomes included time to delivery and maternal and neonatal morbidity. Analysis was done from an intention-to-treat perspective. The trial was registered with the China trial registry (CTR2000038435).

RESULTS

The vaginal birth rates were 72.8% (677/930) vs 69.9% (650/930) in vaginal dinoprostone and Foley catheter, respectively (aRR 1.04, 95% confidence interval [CI] 0.98-1.10, risk difference: 0.03). Time to vaginal delivery was not significantly different between the two groups (sub-distribution hazard ratio 1.11, 95% CI 0.99-1.24). Vaginal dinoprostone was more likely complicated with hyperstimulation with fetal heart rate changes (5.8% vs 2.8%, aRR 2.09, 95% CI 1.32-3.31) and placenta abruption (0.9% vs 0.1%, aRR: 8.04, 95% CI 1.01-64.15), while Foley catheter was more likely complicated with suspected intrapartum infection (5.1% vs 8.2%, aRR: 0.62, 95% CI 0.44-0.88) and postpartum infection (1.4% vs 3.7%, aRR: 0.38, 95% CI 0.20-0.72). The composite of poor neonatal outcomes was not significantly different between the two groups (4.5% vs 3.8%, aRR 1.21, 95% CI 0.78-1.88), while more neonatal asphyxia occurred in the dinoprostone group (1.2% vs 0.2%, aRR 5.39, 95% CI 1.22-23.92). In a subgroup analysis, vaginal dinoprostone decreased vaginal birth rate slightly in multiparous women (90.6% vs 97.0%, aRR 0.93, 95% CI 0.88-0.99).

CONCLUSIONS

In term pregnant women with an unfavorable cervix, IOL with vaginal dinoprostone or Foley catheter has similar effectiveness. Foley catheter leads to better safety for neonates, while it may result in a higher risk of maternal infection. Furthermore, Foley catheter should be preferred in multiparous women.

Cervical ripening balloon compared with vaginal dinoprostone for cervical ripening in obese women at term: A prospective cohort study

OBJECTIVE

To evaluate vaginal delivery in obese women who underwent cervical ripening at term using a dinoprostone vaginal insert or a cervical ripening balloon (CRB), and to assess maternal and neonatal morbidity according to the method.

METHODS

A prospective cohort study including obese women with a live singleton fetus in cephalic presentation who required cervical ripening at term (≥37 weeks) for maternal and/or fetal disease using a dinoprostone vaginal insert or a CRB. The primary outcome was vaginal delivery. Secondary outcomes were a favorable cervix (Bishop score >6) after 24 h, the time from device insertion to delivery, and composite maternal and neonatal morbidity.

RESULTS

In total, 135 consecutive women were analyzed (107 CRB, 79.3%; 28 dinoprostone vaginal insert, 20.7%). Vaginal delivery (86 [80.4%] after CRB vs 19 [67.9%] after dinoprostone vaginal insert; P = 0.248), favorable cervix within 24 h after device placement (52 [48.6%] vs 17 [60.7%]; P = 0.264), and maternal morbidity (12 [11.2%] vs 4 [14.3%]; P = 0.646) were similar between the groups. The time from device insertion to delivery also did not differ between the groups. Neonatal morbidity was significantly higher after the dinoprostone vaginal insert (11 [39.3%] vs 20 [18.7%]; P = 0.030). Cervical ripening using the dinoprostone vaginal insert, compared with the CRB, was significantly associated with neonatal morbidity (adjusted odds ratio 4.00, 95% confidence interval 1.34-12.5), but not with maternal morbidity (adjusted odds ratio 1.23, 95% confidence interval 0.30-4.38).

CONCLUSIONS

Vaginal delivery, a favorable cervix after 24 h, the time from device insertion to delivery, and maternal morbidity did not significantly differ between the CRB and the dinoprostone vaginal insert for cervical ripening in obese women at term. Nevertheless, neonatal morbidity was significantly associated with the dinoprostone vaginal insert, compared with the CRB, among obese women who required cervical ripening at term.

Comparison of two labor induction regimens with intravaginal misoprostol 25 μg and adverse perinatal outcomes

OBJECTIVE

The aim of the study was to compare two labor induction regimens (4 and 6 h), to determine predictors of successful labor induction with intravaginal misoprostol 25 μg tablets, and to evaluate the association with adverse perinatal outcomes.

METHODS

This was a retrospective cohort study that included singleton pregnancies undergoing induction of labor with an intravaginal misoprostol 25 μg tablet between 37 and 42 weeks of gestation. The pregnant women were divided into two groups: Group 1-intravaginal misoprostol 25 μg every 4 h and Group 2-intravaginal misoprostol 25 μg every 6 h.

RESULTS

Pregnant women were divided into Group 1 (n=289) and Group 2 (n=278). Group 1 had a higher median number of intravaginal misoprostol 25 μg tablets (3.0 vs. 2.0 tablets, p<0.001), a lower prevalence of postpartum hemorrhage (7.6 vs. 32.7%, p<0.001), and a higher need for oxytocin (odds ratio [OR]: 2.1, 95%CI: 1.47-2.98, p<0.001) than Group 2. Models including intravaginal misoprostol 25 μg tablets every 4 and 6 h [x2(1)=23.7, OR: 4.35, p<0.0001], parity [x2(3)=39.4, OR: 0.59, p=0.031], and Bishop's score [x2(4)=10.8, OR: 0.77, p=0.019] were the best predictors of failure of labor induction. A statistically significant difference between groups was observed between the use of the first intravaginal misoprostol 25 μg tablet at the beginning (Breslow p<0.001) and the end of the active labor phase (Long Hank p=0.002).

CONCLUSION

Pregnant women who used intravaginal misoprostol 25 μg every 4 h had a longer time from the labor induction to the beginning of the active phase of labor and higher rates of adverse perinatal outcomes than women who used intravaginal misoprostol 25 μg every 6 h.

[Prostaglandins or cervical balloon for the induction of labor for cervical ripening: A literature review]

OBJECTIVE

Induction of labor in France concerns one birth out of four with 70% of induction starting by cervical ripening, either with a pharmacological (prostaglandins) or a mechanical (balloon) method. This review aims to compare these two methods within current knowledge, using the PRISMA methodology.

METHODS

Trials comparing these two methods, published or unpublished up to July 2023, in French or English were searched for in the PubMed, Cochrane Library and ClinicalTrial.govs datasets. Fifty articles including 10,689 women were selected. The outcomes of interest were those from the Core Outcome Set for trails on Induction of Labour (COSIOL) list: mode of delivery, time from induction-to-birth, maternal and neonatal morbidity, and maternal satisfaction.

RESULT

No differences were observed between the two methods for the mode of delivery or neonatal and maternal morbidity. The time from induction-to-birth was longer for mechanical methods. Those were also associated with a greater need for oxytocin, less uterine hyperstimulation and less instrumental deliveries. Maternal satisfaction was assessed in only nine trials using various scales which made the interpretation of maternal satisfaction.

CONCLUSION

The efficacy of these two induction methods is similar for vaginal delivery, but it remains to be seen which one best meets women's satisfaction criteria.

Impact of Introducing a Controlled-Release Dinoprostone Vaginal Insert for Labor Induction: A Retrospective Single-Center Study in Japan

AIM

Cervical ripening is commonly performed before oxytocin administration during labor induction in pregnant women with an unfavorable cervix. In Japan, a controlled-release Dinoprostone vaginal insert (CR-DVI) was approved in 2020. Although many studies have compared the mechanical methods of ripening and prostaglandins, few have examined the impact of additional options for labor induction. This study aimed to assess the impact of CR-DVI as an additional option for labor induction in women with an unfavorable cervix.

METHODS

In this single-center retrospective study conducted in Japan, 265 participants were divided into two groups: before (January 2018 to May 2020) and after (June 2020 to November 2022) CR-DVI introduction. Before CR-DVI was introduced, hygroscopic dilators were used for all cases instead. On the other hand, after the introduction of CR-DVI, the first choice for cervical ripening was CR-DVI. The CR-DVI was retained vaginally for up to 12 hours after insertion. However, if hyper-stimulation or non-reassuring fetal status was suspected, or if a new membrane rupture occurred, it was removed immediately according to the removal criteria. Oxytocin infusions were used during both periods if needed. We compared delivery and neonatal outcomes between the groups.

RESULTS

The 265 participants were divided into two groups: before (n=116) and after (n=149) CR-DVI introduction. There were no significant differences in maternal characteristics except for the primiparous proportion. CR-DVI was used in 93% of cases after introduction. Hygroscopic dilators also continued to be used; however, their use decreased to about 34%. The vaginal delivery rate was significantly higher after the introduction of CR-DVI than before its introduction (50.9% vs. 66.4%; p=0.01). Multivariable analysis revealed a significantly higher rate of vaginal delivery after CR-DVI introduction. Of the 149 cases in which a CR-DVI was used, 111 (79.9%) were removed before 12 hours. There were no significant differences in neonatal outcomes.

CONCLUSION

The rate of vaginal delivery was higher after CR-DVI introduction than before its introduction, and adverse pregnancy outcomes did not increase. Therefore, introducing CR-DVI as an option for labor induction may increase the probability of vaginal delivery. Safety can also be ensured by adhering to the removal criteria.

Is there a difference in labor patterns after induction with prostaglandins and double-balloon catheters?

BACKGROUND

Labor progression curves are believed to differ between spontaneous and induced labors. However, data describing labor progression patterns with different modes of induction are insufficient.

OBJECTIVE

This study aimed to compare the progress patterns between labors induced with slow-release prostaglandin E2 vaginal analogue and those induced with a double-balloon catheter.

STUDY DESIGN

This retrospective cohort study included all nulliparous women who delivered at term and who underwent cervical ripening with prostaglandin E2 vaginal analogue or a double-balloon catheter from 2013 to 2021 in a tertiary hospital in Israel. Included in the analysis were women who achieved 10 cm cervical dilatation. The time intervals between centimeter-to-centimeter changes were evaluated.

RESULTS

A total of 1087 women were included of whom 786 (72.3%) were induced using prostaglandin E2 vaginal analogue and 301 (27.7%) were induced using a double-balloon catheter. The time from induction to birth was similar between the groups (32.5 hours for the prostaglandin E2 vaginal analogue group [5th-95th percentiles, 6.5-153.8] vs 29.2 hours for the double-balloon group [5th-95th percentiles, 9.1-157.1]; P=.100). The median time of the latent phase (2-6 cm dilation) was longer for the double-balloon catheter group than for the prostaglandin E2 vaginal analogue group (7.3 hours [5th-95th percentiles, 5.6-14.5] vs 6.0 hours [5th-95th percentiles, 2.4-18.8]; P=.042). The median time of active labor (6-10 cm dilatation) was similar between groups (1.9 hours [5th-95th percentiles, 0.3-7.4] for the prostaglandin E2 vaginal analogue group vs 2.3 hours [5th-95th percentiles, 0.3-6.5] for the double-balloon catheter group; P=.307).

CONCLUSION

Deliveries subjected to cervical ripening with a double-balloon catheter were characterized by a slightly longer latent phase than deliveries induced by prostaglandin E2 vaginal analogue. After reaching the active phase of labor, the mode of cervical ripening did not influence the labor progress pattern.

Mechanical methods for induction of labour

BACKGROUND

Mechanical methods were the first methods developed to ripen the cervix and induce labour. During recent decades they have been substituted by pharmacological methods. Potential advantages of mechanical methods, compared with pharmacological methods may include reduction in side effects that could improve neonatal outcomes. This is an update of a review first published in 2001, last updated in 2012.

OBJECTIVES

To determine the effectiveness and safety of mechanical methods for third trimester (> 24 weeks' gestation) induction of labour in comparison with prostaglandin E2 (PGE2) (vaginal and intracervical), low-dose misoprostol (oral and vaginal), amniotomy or oxytocin.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies (9 January 2018). We updated the search in March 2019 and added the search results to the awaiting classification section of the review.

SELECTION CRITERIA

Clinical trials comparing mechanical methods used for third trimester cervical ripening or labour induction with pharmacological methods. Mechanical methods include: (1) the introduction of a catheter through the cervix into the extra-amniotic space with balloon insufflation; (2) introduction of laminaria tents, or their synthetic equivalent (Dilapan), into the cervical canal; (3) use of a catheter to inject fluid into the extra-amniotic space (EASI). This review includes the following comparisons: (1) specific mechanical methods (balloon catheter, laminaria tents or EASI) compared with prostaglandins (different types, different routes) or with oxytocin; (2) single balloon compared to a double balloon; (3) addition of prostaglandins or oxytocin to mechanical methods compared with prostaglandins or oxytocin alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review includes a total of 112 trials, with 104 studies contributing data (22,055 women; 21 comparisons). Risk of bias of trials varied. Overall, the evidence was graded from very-low to moderate quality. All evidence was downgraded for lack of blinding and, for many comparisons, the effect estimates were too imprecise to make a valid judgement.   Balloon versus vaginal PGE2: there may be little or no difference in vaginal deliveries not achieved within 24 hours (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.82 to 1.26; 7 studies; 1685 women; low-quality evidence) and there probably is little or no difference in caesarean sections (RR 1.00, 95% CI 0.92 to 1.09; 28 studies; 6619 women; moderate-quality evidence) between induction of labour with a balloon catheter and vaginal PGE2. A balloon catheter probably reduces the risk of uterine hyperstimulation with fetal heart rate (FHR) changes (RR 0.35, 95% CI 0.18 to 0.67; 6 studies; 1966 women; moderate-quality evidence), serious neonatal morbidity or perinatal death (RR 0.48, 95% CI 0.25 to 0.93; 8 studies; 2757 women; moderate-quality evidence) and may slightly reduce the risk of aneonatal intensive care unit (NICU) admission (RR 0.82, 95% CI 0.65 to 1.04; 3647 women; 12 studies; low-quality evidence). It is uncertain whether there is a difference in serious maternal morbidity or death (RR 0.20, 95% CI 0.01 to 4.12; 4 studies; 1481 women) or five-minute Apgar score < 7 (RR 0.74, 95% CI 0.49 to 1.14; 4271 women; 14 studies) because the quality of the evidence was found to be very low and low, respectively. Balloon versus low-dose vaginal misoprostol: it is uncertain whether there is a difference in vaginal deliveries not achieved within 24 hours between induction of labour with a balloon catheter and vaginal misoprostol (RR 1.09, 95% CI 0.85 to 1.39; 340 women; 2 studies; low-quality evidence). A balloon catheter probably reduces the risk of uterine hyperstimulation with FHR changes (RR 0.39, 95% CI 0.18 to 0.85; 1322 women; 8 studies; moderate-quality evidence) but may increase the risk of a caesarean section (RR 1.28, 95% CI 1.02 to 1.60; 1756 women; 12 studies; low-quality evidence). It is uncertain whether there is a difference in serious neonatal morbidity or perinatal death (RR 0.58, 95% CI 0.12 to 2.66; 381 women; 3 studies), serious maternal morbidity or death (no events; 4 studies, 464 women), both very low-quality evidence, and five-minute Apgar score < 7 (RR 1.00, 95% CI 0.50 to 1.97; 941 women; 7 studies) and NICU admissions (RR 1.00, 95% CI 0.61 to 1.63; 1302 women; 9 studies) both low-quality evidence. Balloon versus low-dose oral misoprostol: a balloon catheter probably increases the risk of a vaginal delivery not achieved within 24 hours (RR 1.28, 95% CI 1.13 to 1.46; 782 women, 2 studies, and probably slightly increases the risk of a caesarean section (RR 1.17, 95% CI 1.04 to 1.32; 3178 women; 7 studies; both moderate-quality evidence) when compared to oral misoprostol. It is uncertain whether there is a difference in uterine hyperstimulation with FHR changes (RR 0.81, 95% CI 0.48 to 1.38; 2033 women; 2 studies), serious neonatal morbidity or perinatal death (RR 1.11, 95% CI 0.60 to 2.06; 2627 women; 3 studies), both low-quality evidence, serious maternal morbidity or death (RR 0.50, 95% CI 0.05 to 5.52; 2627 women; 3 studies), very low-quality evidence, five-minute Apgar scores < 7 (RR 0.71, 95% CI 0.38 to 1.32; 2693 women; 4 studies) and NICU admissions (RR 0.82, 95% CI 0.58 to 1.17; 2873 women; 5 studies) both low-quality evidence.

AUTHORS' CONCLUSIONS

Low- to moderate-quality evidence shows mechanical induction with a balloon is probably as effective as induction of labour with vaginal PGE2. However, a balloon seems to have a more favourable safety profile. More research on this comparison does not seem warranted. Moderate-quality evidence shows a balloon catheter may be slightly less effective as oral misoprostol, but it remains unclear if there is a difference in safety outcomes for the neonate. When compared to low-dose vaginal misoprostol, low-quality evidence shows a balloon may be less effective, but probably has a better safety profile. Future research could be focused more on safety aspects for the neonate and maternal satisfaction.

Intra-cervical Foley Balloon Catheter Versus Prostaglandins for the Induction of Labour: A Literature Review

Labour induction involves helping a woman to start her labour, before labour begins on its own, for a vaginal birth with the aid of artificial methods, such as medications or other medical techniques. Labour induction is done in cases where extending the pregnancy can threaten the mother or her baby's health, and delivery should result in better outcomes than continuing the pregnancy. Currently, nearly 25% of babies are born by labour induction in economically developed countries. It is often necessary in certain situations to induce labour by using ripening techniques that not only soften the cervix but also make it thin and dilated. Mechanical or pharmacological approaches are used for the artificial induction of labour. Because research articles evaluating the safety and efficacy of various ripening techniques of the cervix vary in terms of their findings, it remains uncertain as to which is the best way to induce labour. In light of this, to find out the most popular interventions for ripening of the cervix during labour induction, we performed a review of the literature that compares the use of a Foley catheter and prostaglandins (misoprostol and dinoprostone). Our findings show that using misoprostol orally is much better than using it vaginally. Foley catheter proved to be the least effective induction technique, despite the fact that it offers the lowest risk.

Balloon catheters versus vaginal prostaglandins for labour induction (CPI Collaborative): an individual participant data meta-analysis of randomised controlled trials

BACKGROUND

Induction of labour is one of the most common obstetric interventions globally. Balloon catheters and vaginal prostaglandins are widely used to ripen the cervix in labour induction. We aimed to compare the effectiveness and safety profiles of these two induction methods.

METHODS

We did an individual participant data meta-analysis comparing balloon catheters and vaginal prostaglandins for cervical ripening before labour induction. We systematically identified published and unpublished randomised controlled trials that completed data collection between March 19, 2019, and May 1, 2021, by searching the Cochrane Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and PubMed. Further trials done before March 19, 2019, were identified through a recent Cochrane review. Data relating to the combined use of the two methods were not included, only data from women with a viable, singleton pregnancy were analysed, and no exclusion was made based on parity or membrane status. We contacted authors of individuals trials and participant-level data were harmonised and recoded according to predefined definitions of variables. Risk of bias was assessed with the ROB2 tool. The primary outcomes were caesarean delivery, indication for caesarean delivery, a composite adverse perinatal outcome, and a composite adverse maternal outcome. We followed the intention-to-treat principle for the main analysis. The primary meta-analysis used two-stage random-effects models and the sensitivity analysis used one-stage mixed models. All models were adjusted for maternal age and parity. This meta-analysis is registered with PROSPERO (CRD42020179924).

FINDINGS

Individual participant data were available from 12 studies with a total of 5460 participants. Balloon catheters, compared with vaginal prostaglandins, did not lead to a significantly different rate of caesarean delivery (12 trials, 5414 women; crude incidence 27·0%; adjusted OR [aOR] 1·09, 95% CI 0·95-1·24; I²=0%), caesarean delivery for failure to progress (11 trials, 4601 women; aOR 1·20, 95% CI 0·91-1·58; I²=39%), or caesarean delivery for fetal distress (10 trials, 4441 women; aOR 0·86, 95% CI 0·71-1·04; I²=0%). The composite adverse perinatal outcome was lower in women who were allocated to balloon catheters than in those allocated to vaginal prostaglandins (ten trials, 4452 neonates, crude incidence 13·6%; aOR 0·80, 95% CI 0·70-0·92; I²=0%). There was no significant difference in the composite adverse maternal outcome (ten trials, 4326 women, crude incidence 22·7%; aOR 1·02, 95% CI 0·89-1·18; I²=0%).

INTERPRETATION

In induction of labour, balloon catheters and vaginal prostaglandins have comparable caesarean delivery rates and maternal safety profiles, but balloon catheters lead to fewer adverse perinatal events.

FUNDING

Australian National Health and Medical Research Council and Monash Health Emerging Researcher Fellowship.

Safety and efficacy of double-balloon catheter for cervical ripening: a Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

Various methods are used for cervical ripening during the induction of labor. Mechanical and pharmacological methods are commonly used for cervical ripening. A double-balloon catheter was specifically developed to ripen the cervix and induce labor; however, the efficacy of the double-balloon catheter in cervical ripening compared to other methods is unknown.

METHODS

We searched five databases and performed a Bayesian network meta-analysis. Six interventions (double-balloon catheter, Foley catheter, oral misoprostol, vaginal misoprostol, dinoprostone, and double-balloon catheter combined with oral misoprostol) were included in the search. The primary outcomes were cesarean delivery rate and time from intervention-to-birth. The secondary outcomes were as follows: Bishop score increment; achieving a vaginal delivery within 24 h; uterine hyperstimulation with fetal heart rate changes; need for oxytocin augmentation; instrumental delivery; meconium staining; chorioamnionitis; postpartum hemorrhage; low Apgar score; neonatal intensive care unit admission; and arterial pH.

RESULTS

Forty-eight randomized controlled trials involving 11,482 pregnant women were identified. The cesarean delivery rates of the cervical ripening with a double-balloon catheter and oral misoprostol, oral misoprostol, and vaginal misoprostol were significantly lower than cervical ripening with a Foley catheter (OR = 0.48, 95% CI: 0.23-0.96; OR = 0.74, 95% CI: 0.58-0.93; and OR = 0.79, 95% CI: 0.64-0.97, respectively; all P < 0.05). The time from intervention-to-birth of vaginal misoprostol was significantly shorter than the other five cervical ripening methods. Vaginal misoprostol and oral misoprostol increased the risk of uterine hyperstimulation with fetal heart rate changes compared to a Foley catheter. A double-balloon catheter with or without oral misoprostol had similar outcomes, including uterine hyperstimulation with fetal heart rate changes compared to a Foley catheter.

CONCLUSION

Double-balloon catheter did not show superiority when compared with other single method in primary and secondary outcomes of labor induction. The combination of double-balloon catheter with oral misoprostol was significantly reduced the rate of cesarean section compared to Foley catheter without increased risk of uterine hyperstimulation with fetal heart rate changes, which was shown in oral or vaginal misoprostol.

A randomized trial of synthetic osmotic cervical dilator for induction of labor vs dinoprostone vaginal insert

BACKGROUND

Induction of labor is a commonly performed obstetrical intervention. Vaginal prostaglandin E2 (dinoprostone) is a first-choice agent. Mechanical methods of induction are slower in achieving cervical ripening but have a lower risk of adverse effects.

OBJECTIVE

This study aimed to compare the efficacy, maternal and neonatal safety, and maternal satisfaction of a synthetic osmotic cervical dilator (Dilapan-S) with those of dinoprostone.

STUDY DESIGN

This was an open-label superiority randomized controlled trial in 4 English hospitals. Eligible participants were women ≥16 years of age undergoing induction of labor for a singleton pregnancy at ≥37 weeks' gestation with vertex presentation and intact membranes. The women were randomly assigned to receive either Dilapan-S or dinoprostone using a telephone randomization system minimized by hospital, parity, body mass index, and maternal age. The induction agent was replaced as required until the cervix was assessed as favorable for labor by the Bishop score. The primary outcome was failure to achieve vaginal delivery (ieor a cesarean delivery being performed). The secondary outcome measures included maternal and neonatal adverse events. Analysis was by intention-to-treat, adjusting for design variables where possible.

RESULTS

Between December 19, 2017 and January 26, 2021, 674 women were randomized (337 to Dilapan-S, and 337 to dinoprostone). The trial did not reach its planned sample size of 860 participants because of restrictions on research during the COVID-19 pandemic. The primary outcome was missing for 2 women in the dinoprostone group. Failure to achieve vaginal delivery (or a cesarean delivery being performed) occurred in 126 women (37.4%) allocated to Dilapan-S and in 115 (34.3%) women allocated to dinoprostone (adjusted risk difference, 0.02; 95% confidence interval, -0.05 to 0.10). There were similar maternal and neonatal adverse events between the groups.

CONCLUSION

Women undergoing induction of labor with Dilapan-S have similar rates of cesarean delivery and maternal and neonatal adverse events compared with dinoprostone.

Comparison of intracervical Foley catheter combined with a single dose of vaginal misoprostol tablet or intracervical dinoprostone gel for cervical ripening: a randomised study

We compared two combined methods for cervical ripening before induction of labour (IOL) Women (n = 150) were randomised into Foley's-misoprostol (n = 75) and Foley's-dinoprostone (n = 75) groups. A single dose of vaginal misoprostol tablet (25 µg) or intracervical dinoprostone gel (0.5 mg) were used alongwith intracervical Foley's. The primary outcome was induction-delivery interval (IDI) and secondary outcomes were change in Bishop's score, oxytocin requirement, caesarean section (CS) rate, chorioamnionitis and neonatal outcome. The mean parity, gestation and indications for IOL were similar in the two groups. The IDI (19 h 37 min and 19 h 20 min; p = .683), cervical ripening time, oxytocin requirement, CS rate (18.7 and 25.4%, p = .322) and neonatal outcome were similar. Hyperstimulation developed in 2.7% women with Foley's-misoprostol and in 1.3% with Foley's-dinoprostone (p = .55). No woman had chorioamnionitis. Thus, these two combined methods of cervical ripening and IOL were observed to be similarly efficacious. A low incidence of hyperstimulation and no chorioamnionitis may be attributed to using a single dose of prostaglandins. Misoprostol may be substituted for dinoprostone in resource limited countries.Impact statementWhat is already known on this subject? Combined methods for cervical ripening (intracervical Foley's plus prostaglandins) before induction of labour (IOL) may be similarly or more efficacious than individual methods. Most studies comparing various combined methods have used repeated doses of prostaglandins. A combined method using repetitive doses of prostaglandins may increase the risk of hyperstimulation and also of infection consequent to repeated vaginal examination to administer prostaglandins. These two concerns may be offset by combining a single dose of prostaglandin with intracervical Foley's catheter.What do the results of this study add? Two combined methods for cervical ripening using a single dose of vaginal misoprostol (25 µg) or intracervical dinoprostone gel (0.5 mg) co-administered with intracervical Foley's catheter were found to be similarly efficacious. The IDI (19 h 37 min and 19 h 20 min; p = .683), cervical ripening time, oxytocin requirement, CS rate (18.7 and 25.4%, p = .322) and neonatal outcome were similar. The incidence of hyperstimulation was low (2.7 and 1.3% with Foley's-misoprostol and Foley's-dinoprostone, respectively) and no woman had chorioamnionitis.What are the implications of these findings for clinical practice and/or further research? Combined methods for cervical ripening using a single dose of prostaglandins (misoprostol or dinoprostone) were observed to be similarly efficacious. Misoprostol is a cheaper alternative to dinoprostone and may be utilised in resource limited countries. These methods may be compared with each other in more number of women in order to identify which combined method is more efficient and safe. Clinical Trials Registry of India: CTRI/2017/12/010738.

Dinoprostone vaginal insert (DVI) versus adjunctive sweeping of membranes and DVI for term induction of labor

AIM

To compare the efficacy and safety of dinoprostone vaginal insert (DVI) alone versus DVI with adjunctive sweeping of membranes (ASM) for induction of labor (IOL).

METHODS

Single-center, prospective, randomized controlled trial; women with singleton term pregnancies, cervical dilation ≥1 and <3 cm, intact membranes allocated to either DVI or DVI with ASM. The primary outcome was vaginal delivery within 24 h of insertion. Secondary outcomes included mean time from insertion to delivery, tachysystole, operative delivery for non-reassuring fetal status (NRFS), tocolytics, fetal outcomes, pain information, and subject satisfaction.

RESULTS

One hundred and four received DVI (Group 1) alone and 104 DVI with ASM (Group 2). The rate of vaginal delivery within 24 h was 53% versus 56%, cesarean rate 8.7% versus 10.6% in Groups 1 and 2 respectively. Although the duration of labor was similar in both groups, about 6% of women required additional ripening with dinoprostone vaginal tablets in Group 2 compared to 11.5% in Group 1 (p-value = 0.2). The frequency of hyperstimulation syndrome, failed induction, analgesic requirements, and fetal outcomes were comparable. The majority (83%-86%) in either cohort were satisfied with their labor experience. Multivariate logistic regression demonstrated a slightly better chance for vaginal delivery within 24 h (odds ratio [OR] 1.22 [95% confidence interval, CI 0.65-2.29]; p-value 0.53] for DVI with ASM, although statistically insignificant. Younger maternal age and multiparity (OR 10.36 [95% CI 4.88-23.67]; p-value <0.0001) contributed to successful IOL.

CONCLUSION

DVI with ASM is at least as efficacious as DVI for cervical ripening with no increase in morbidity. Although DVI with ASM group less often needed additional dinoprostone tablets to complete the process of IOL (p-value = 0.2), adjunctive sweeping has not been shown to have a significant impact on the duration of labor or mode of delivery.

Controlled Release Dinoprostone Insert and Foley Compared to Foley Alone: A Randomized Pilot Trial

OBJECTIVE

The aim of study is to compare, in a pilot study, combined dinoprostone vaginal insert and Foley catheter (DVI + Foley) with Foley alone (Foley) for cervical ripening and labor induction at term.

STUDY DESIGN

In this open-label pilot randomized controlled trial, women not in labor, with intact membranes, no prior uterine incision, an unfavorable cervix, gestational age ≥37 weeks, and a live, nonanomalous singleton fetus in cephalic presentation were randomly assigned, stratified by parity, to DVI + Foley or Foley. Oxytocin was used in both groups after cervical ripening. Primary outcome was time to vaginal delivery.

RESULTS

From April 2017 to January 2018, 100 women were randomized. Median (25-75th percentile) time to vaginal delivery for nulliparous women was 21.2 (16.6-38.0) hours with DVI + Foley (n = 26) compared with 31.3 (23.3-46.9) hours with Foley (n = 24) (Wilcoxon p = 0.05). Median time to vaginal delivery for parous women was 17.1 (13.6-21.9) hours with DVI + Foley (n = 25) compared with 14.8 (12.7-19.5) hours with Foley (n = 25) (Wilcoxon p = 0.21). Results were also analyzed to consider the competing risk of cesarean using cumulative incidence functions.

CONCLUSION

Compared with Foley alone, combined use of the dinoprostone vaginal insert and Foley for cervical ripening may shorten time to vaginal delivery for nulliparous but not parous women.

Morbidity associated with the use of Foley balloon for cervical ripening in women with prior cesarean delivery

OBJECTIVE

We evaluated the morbidity of Foley balloon for cervical ripening in comparison to oxytocin alone in women with a prior cesarean delivery.

STUDY DESIGN

A four-hospital retrospective review of all women with viable singleton pregnancies and history of a single prior cesarean delivery presenting for cervical ripening between 1994 and 2015. Exposure groups were either Foley balloon or oxytocin, at the treating physician's discretion. The primary outcome was defined as maternal morbidity, evaluated by a composite that included hemorrhage, and/or uterine infection, and/or uterine rupture. We defined two secondary outcomes: neonatal morbidity, and vaginal delivery rate. Neonatal morbidity was evaluated by a composite that included five-minute APGAR score <7 and/or NICU admission. We adjusted results for potential confounding variables, including hospital site, maternal age and race, initial cervical dilation, and gestational age at delivery.

RESULTS

We identified 688 patients who received ripening, 276 by Foley balloon and 412 by oxytocin. There was no significant difference in the primary outcome of maternal morbidity between groups: 38 (13.8%) in the Foley balloon group and 79 (19.2%) in the oxytocin group (aOR 1.43; 95% CI, 0.90-2.27). There was no significant difference in the secondary outcome of neonatal morbidity: 31 (11.3%) in the Foley balloon group and 51 (12.4%) in the oxytocin group (aOR 1.02; 95% CI, 0.57-1.80). The rate of vaginal delivery was significantly less in the Foley balloon group compared to the oxytocin group: 56.2% vs 64.1%, p = .037.

CONCLUSION

When cervical ripening with either Foley balloon or oxytocin was utilized at the physician's discretion in women with prior cesarean, there was no identified difference in maternal and neonatal morbidity, but the rate of successful vaginal delivery was lower.

Effectiveness of Dinoprostone and Cook's Balloon for Labor Induction in Primipara Women at Term

Labor induction is commonly used for achieving successful vaginal delivery. This study aimed to compare the effectiveness of dinoprostone and Cook's balloon as labor-inducing agents in primipara women at term. A retrospective cohort study among primipara women was conducted in Hubei Maternity and Child Health Hospital. Basic clinical characteristics were collected. The main outcomes were vaginal delivery rate, cesarean section rate and forceps delivery rate. Obstetric and perinatal outcomes were also compared. Univariate and multivariate analyses were further performed to evaluate the predictors for vaginal delivery within 24 h. A total of 845 eligible primipara women undergoing labor induction were recruited. Of them, 141 women were induced with dinoprostone (dinoprostone group, DG), and 704 with Cook's balloon (Cook's balloon group, CG). Groups were homogeneous except more women with premature rupture of membranes in DG, with gestational hypertension in CG (P<0.05). The vaginal delivery rate within 12 h was 1.98% and 16.52% in CG and DG respectively (P=0.0001). Besides, the vaginal delivery rate within 24 h was 37.62% and 52.26% in CG and DG respectively (P=0.0079). DG showed the lower rate of oxytocin augmentation, artificial rupture of membrane and postpartum hemorrhage and the shorter interval from insertion to active labor than CG (P<0.05). Multivariate regression analysis revealed that abortion history, oxytocin augmentation, artificial rupture of membrane, and obstetric analgesia were independent predictors for vaginal delivery within 24 h. In conclusion, dinoprostone was more effective than Cook's balloon to induce labor and achieve vaginal birth in the sample of primipara women at term.

Retrospective Comparison of PGE2 Vaginal Insert and Foley Catheter for Outpatient Cervical Ripening

OBJECTIVE

To compare the efficacy of two methods of outpatient cervical ripening (CR): an intracervical Foley catheter and a prostaglandin E₂ (PGE)₂ slow-release vaginal insert.

METHODS

All records of women receiving outpatient CR at a tertiary care hospital from January 2017 to June 2018 were retrospectively reviewed. We compared time from insertion of first CR agent until delivery between groups using a Cox proportional hazards (CPH) model. Exclusion criteria included age <18 years, multiple gestation, or contraindication to either CR method. Secondary outcomes included time from removal of agent and time from admission until delivery, additional CR used, uterine tachysystole, labour and delivery complications, type of delivery, and adverse neonatal outcomes.

RESULTS

A total of 153 patients were included (82 Foley; 71 PGE₂). Baseline characteristics were comparable except for lower dilation in the PGE₂ group (16% vs. 38% <1cm dilated; P < 0.05). In the CPH model, time from insertion to delivery was not different between PGE₂ and Foley catheter groups (median 27 vs. 33 h), controlling for parity, gestational age, initial dilation, and use of oxytocin (HR 1.13, 95% confidence interval 0.77-1.68). Patients in the PGE₂ group were more likely to experience uterine tachysystole (9% vs. 0%; P < 0.01) and require another method of CR (34% vs. 1%; P < 0.001). There were no differences in neonatal or maternal adverse outcomes between groups.

CONCLUSION

Our results suggest that outpatient Foley catheter and PGE₂ CR are comparable in time from insertion to delivery; however, PGE₂ inserts are associated with higher rates of tachysystole and the need for second CR method. A prospective study is warranted to further investigate these findings.

Comparing Foley Catheter to Prostaglandins for Cervical Ripening in Multiparous Women

OBJECTIVE

This study sought to test the hypothesis that among multiparous women requiring cervical ripening, mechanical ripening with a Foley catheter is more effective than prostaglandin preparations.

METHODS

This was a retrospective analysis of multiparous women with a singleton gestation who required cervical ripening in a single tertiary center from 2014 to 2019. Women who underwent cervical ripening with a Foley catheter (Foley group) were compared with women who underwent cervical ripening using a controlled-release dinoprostone vaginal insert (PGE₂-CR group) or dinoprostone vaginal gel (PGE₂-gel group). The primary outcome was the ripening-to-delivery interval.

RESULTS

A total of 229 women met the study criteria (Foley group: 95; PGE₂-CR group: 83; PGE₂-gel group: 51). Women in the Foley group had a significantly shorter ripening-to-delivery interval compared with women in the PGE₂-CR group (16.2 ± 9.2 hours vs. 27.0 ± 14.8 hours; P < 0.001) and were more likely to deliver within 12 hours (47.4% vs. 12.0%; P < 0.001; adjusted relative risk [aRR] 3.87; 95% confidence interval [CI] 2.07-7.26) and within 24 hours (78.9% vs. 49.4%; P < 0.001; aRR 1.61; 95% CI 1.26-2.06). Women in the Foley group were also less likely to require a second ripening method compared with women in the PGE₂-CR group (1.1% vs. 8.4%; P = 0.018; aRR 7.26; 95% CI 2.99-17.62). These differences were not observed when comparing the Foley and the PGE₂-gel groups. The cesarean section rate was similar among the Foley group (9.5%), PGE₂-CR group (9.6%; P = 0.970), and PGE₂-gel group (11.8%; P = 0.664).

CONCLUSION

In multiparous women requiring cervical ripening, all methods of cervical ripening have a similar success rate. However, the use of a PGE₂-CR insert is associated with a considerably longer interval to delivery compared with a Foley catheter or PGE₂ gel.

Mechanical methods for induction of labour

BACKGROUND

Mechanical methods were the first methods developed to ripen the cervix and induce labour. During recent decades they have been substituted by pharmacological methods. Potential advantages of mechanical methods, compared with pharmacological methods may include reduction in side effects that could improve neonatal outcomes. This is an update of a review first published in 2001, last updated in 2012.

OBJECTIVES

To determine the effectiveness and safety of mechanical methods for third trimester (> 24 weeks' gestation) induction of labour in comparison with prostaglandin E2 (PGE2) (vaginal and intracervical), low-dose misoprostol (oral and vaginal), amniotomy or oxytocin.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies (9 January 2018). We updated the search in March 2019 and added the search results to the awaiting classification section of the review.

SELECTION CRITERIA

Clinical trials comparing mechanical methods used for third trimester cervical ripening or labour induction with pharmacological methods.Mechanical methods include: (1) the introduction of a catheter through the cervix into the extra-amniotic space with balloon insufflation; (2) introduction of laminaria tents, or their synthetic equivalent (Dilapan), into the cervical canal; (3) use of a catheter to inject fluid into the extra-amniotic space (EASI).This review includes the following comparisons: (1) specific mechanical methods (balloon catheter, laminaria tents or EASI) compared with prostaglandins (different types, different routes) or with oxytocin; (2) single balloon compared to a double balloon; (3) addition of prostaglandins or oxytocin to mechanical methods compared with prostaglandins or oxytocin alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review update includes a total of 113 trials (22,373 women) contributing data to 21 comparisons. Risk of bias of trials varied. Overall, the evidence was graded from very-low to moderate quality. All evidence was downgraded for lack of blinding and, for many comparisons, the effect estimates were too imprecise to make a valid judgement.Balloon versus vaginal PGE2: there may be little or no difference in vaginal deliveries not achieved within 24 hours (average risk ratio (RR) 1.01, 95% confidence interval (CI) 0.82 to 1.26; 7 studies; 1685 women; I² = 79%; low-quality evidence) and there probably is little or no difference in caesarean sections (RR 1.00, 95% CI 0.92 to 1.09; 28 studies; 6619 women; moderate-quality evidence) between induction of labour with a balloon catheter and vaginal PGE2. A balloon catheter probably reduces the risk of uterine hyperstimulation with fetal heart rate (FHR) changes (RR 0.35, 95% CI 0.18 to 0.67; 6 studies; 1966 women; moderate-quality evidence), serious neonatal morbidity or perinatal death (RR 0.48, 95% CI 0.25 to 0.93; 8 studies; 2757 women; moderate-quality evidence) and may slightly reduce the risk of aneonatal intensive care unit (NICU) admission (RR 0.82, 95% CI 0.65 to 1.04; 3647 women; 12 studies; low-quality evidence). It is uncertain whether there is a difference in serious maternal morbidity or death (RR 0.20, 95% CI 0.01 to 4.12; 4 studies; 1481 women) or five-minute Apgar score < 7 (RR 0.74, 95% CI 0.49 to 1.14; 4271 women; 14 studies) because the quality of the evidence was found to be very low and low, respectively.Balloon versus low-dose vaginal misoprostol: it is uncertain whether there is a difference in vaginal deliveries not achieved within 24 hours between induction of labour with a balloon catheter and vaginal misoprostol (RR 1.09, 95% CI 0.85 to 1.39; 340 women; 2 studies; low-quality evidence). A balloon catheter probably reduces the risk of uterine hyperstimulation with FHR changes (RR 0.39, 95% CI 0.18 to 0.85; 1322 women; 8 studies; moderate-quality evidence) but may increase the risk of a caesarean section (average RR 1.28, 95% CI 1.02 to 1.60; 1756 women; 12 studies; I² = 45%; low-quality evidence). It is uncertain whether there is a difference in serious neonatal morbidity or perinatal death (RR 0.58, 95% CI 0.12 to 2.66; 381 women; 3 studies), serious maternal morbidity or death (no events; 4 studies, 464 women), both very low-quality evidence, and five-minute Apgar score < 7 (RR 1.00, 95% CI 0.50 to 1.97; 941 women; 7 studies) and NICU admissions (RR 1.00, 95% CI 0.61 to 1.63; 1302 women; 9 studies) both low-quality evidence.Balloon versus low-dose oral misoprostol: a balloon catheter probably increases the risk of a vaginal delivery not achieved within 24 hours (RR 1.28, 95% CI 1.13 to 1.46; 782 women, 2 studies, and probably slightly increases the risk of a caesarean section (RR 1.17, 95% CI 1.04 to 1.32; 3178 women; 7 studies; both moderate-quality evidence) when compared to oral misoprostol. It is uncertain whether there is a difference in uterine hyperstimulation with FHR changes (RR 0.81, 95% CI 0.48 to 1.38; 2033 women; 2 studies), serious neonatal morbidity or perinatal death (RR 1.11, 95% CI 0.60 to 2.06; 2627 women; 3 studies), both low-quality evidence, serious maternal morbidity or death (RR 0.50, 95% CI 0.05 to 5.52; 2627 women; 3 studies), very low-quality evidence, five-minute Apgar scores < 7 (RR 0.71, 95% CI 0.38 to 1.32; 2693 women; 4 studies) and NICU admissions (RR 0.82, 95% CI 0.58 to 1.17; 2873 women; 5 studies) both low-quality evidence.

AUTHORS' CONCLUSIONS

Low- to moderate-quality evidence shows mechanical induction with a balloon is probably as effective as induction of labour with vaginal PGE2. However, a balloon seems to have a more favourable safety profile. More research on this comparison does not seem warranted.Moderate-quality evidence shows a balloon catheter may be slightly less effective as oral misoprostol, but it remains unclear if there is a difference in safety outcomes for the neonate. When compared to low-dose vaginal misoprostol, low-quality evidence shows a balloon may be less effective, but probably has a better safety profile.Future research could be focused more on safety aspects for the neonate and maternal satisfaction.

Outpatient Foley Catheter for Induction of Labor in Parous Women: A Randomized Controlled Trial

OBJECTIVE

To assess whether outpatient cervical ripening with a transcervical Foley catheter in parous women undergoing elective induction of labor shortens the total duration of time from admission to the labor ward until delivery.

METHODS

We performed an open-label randomized controlled trial at a single academic center in parous women at 39 weeks of gestation or greater with a cervix 3 cm or less dilated, or, if 2-3 cm dilated, less than 80% effaced and reassuring fetal heart rate monitoring (defined as moderate variability with a normal baseline and absence of decelerations). Exclusions were obstetric and neonatal conditions deemed unsuitable for outpatient cervical ripening, contraindications to vaginal delivery, or conditions that required immediate hospitalization. Women were randomized in the ambulatory setting to either an outpatient transcervical catheter (with immediate placement) or inpatient transcervical catheter placement and concomitant oxytocin infusion on the labor ward. Women in the outpatient group were instructed to return to the hospital the next day or sooner if labor occurred. Induction of labor was managed per institutional protocol, and once participants were admitted, oxytocin was initiated. The primary outcome was the duration of time from labor ward admission until delivery. Based on a prior study in our institution, a total of 128 women were needed for 80% power to detect a 12-hour difference in total duration spent from labor ward admission until delivery with a two-sided α of 0.05.

RESULTS

Of 743 women screened, 129 provided consent and were randomized from May 2016 to October 2017. Baseline characteristics were balanced between groups. Outpatient cervical ripening did not significantly shorten the time from labor ward admission until delivery (12.4±7.4 vs 13.5±7.0 hours, P=.38).

CONCLUSION

Outpatient cervical ripening in parous women does not shorten the time from labor ward admission until delivery if oxytocin is initiated simultaneously with inpatient transcervical catheter placement.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02756689.

A randomized controlled trial of Dilapan-S vs Foley balloon for preinduction cervical ripening (DILAFOL trial)

OBJECTIVE

The objective of the study was to test the hypothesis that Dilapan-S is not inferior to the Foley balloon for preinduction cervical ripening at term.

STUDY DESIGN

Pregnant women ≥37 weeks scheduled for induction with unfavorable cervix (≤3 cm dilated and ≤60% effaced) were randomly assigned to 12 hours of either Foley balloon inflated with 60 mL saline or Dilapan-S for cervical ripening. If the cervix remained unfavorable, then 1 more round of the assigned dilator was used. Management following ripening was left up to the clinical providers. The primary outcome was vaginal delivery. A satisfaction survey was also obtained after the preinduction period. Sample size was based on a noninferiority margin of 10%, 90% power, and an estimated frequency of vaginal delivery of 71% in Foley balloon and 76% in Dilapan-S.

RESULTS

From November 2016 through February 2018, 419 women were randomized (209 to Foley balloon; 210 to Dilapan-S). In the intent-to-treat analysis, vaginal delivery was more common in Dilapan-S vs Foley balloon (81.3% vs 76.1%), with an absolute difference with respect to the Foley balloon of 5.2% (95% confidence interval, -2.7% to 13.0%) indicating noninferiority for the prespecified margin. The difference was not large enough to show superiority. Noninferiority was confirmed in the per-protocol population (n = 204 in the Foley balloon, n = 188 in Dilapan-S), supporting the robustness of the results. Secondary outcomes were not different between groups, except for a longer time the device remained in place in Dilapan-S compared with the Foley balloon. Maternal and neonatal adverse events were not significantly different between groups. A priori interaction analyses showed no difference in the effect on vaginal delivery by cervical dilation at randomization, parity, or body mass index >30 kg/m². Patients with Dilapan-S were more satisfied than patients with the Foley balloon as far as sleep (P = .01), relaxing time (P = .001), and performance of desired daily activities (P = .001).

CONCLUSION

Dilapan-S is not inferior to the Foley balloon for preinduction cervical ripening at term. Advantages of Dilapan-S over Foley include Food and Drug Administration approval, safe profile, no protrusion from the introitus, no need to keep under tension, and better patient satisfaction.

Double-balloon catheter versus dinoprostone insert for labour induction: a meta-analysis

OBJECTIVE

To assess the efficacy and safety of a double-balloon catheter versus dinoprostone insert for labour induction.

STUDY DESIGN

PubMed, MEDLINE, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Clinical Trials databases were searched from 1985 to April 2018. Randomized controlled trials that compared a double-balloon catheter and dinoprostone insert for cervical ripening were identified. Eligible study populations consisted of women with singleton pregnancies that had any indication for labour induction and were randomly assigned to undergo induction with a double-balloon catheter or dinoprostone insert. The main outcomes were incidence of vaginal delivery within 24 h and caesarean section, and neonatal outcomes.

RESULTS

Five randomized trials (603 women; 305 with a double-balloon catheter and 298 with a dinoprostone insert) were eligible for inclusion. No differences were observed between the two groups in terms of vaginal delivery within 24 h [relative risk (RR) 1.21, 95% confidence interval (CI) 0.93-1.59] and incidence of caesarean section (RR 0.99, 95% CI 0.77-1.27). Compared with the double-balloon catheter, the dinoprostone insert was associated with a reduced need for oxytocin administration in the process of labour induction (RR 1.95, 95% CI 1.45-2.62). However, there was a higher incidence of excessive uterine activity (RR 0.17, 95% CI 0.06-0.54) and neonatal umbilical cord arterial blood pH < 7.1 (RR 0.36, 95% CI 0.15-0.84) in the dinoprostone insert group.

CONCLUSION

This review showed that the efficacy of labour induction using both the double-balloon catheter and dinoprostone insert was similar. However, the double-balloon catheter seemed to be a safer method.

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.

[Cervical ripening and labor induction: Evaluation of single balloon catheter compared to double balloon catheter and dinoprostone insert]

OBJECTIVE

To compare the effectiveness of single balloon catheter with double balloon catheter and dinoprostone insert for cervical ripening and labor induction on unfavourable cervix.

METHODS

this is a comparative, retrospective, one-center trial. Were included singleton pregnancy in cephalic presentation. Were excluded cicatricial uterus. The outcomes were vaginal delivery rate, caesarean section rate, modification in Bishop score, time from induction to delivery, second time prostaglandin E2 resort, oxytocin administration resort, maternal or neonatal adverse events.

RESULTS

Were included 108 patients: 45 in single balloon catheter group, 32 in double balloon catheter group, 31 in dinoprostone insert group. Vaginal delivery rate was similar in single balloon catheter group (78 %) compared with others groups (75 % in double balloon catheter and 71 % in dinoprostone insert group respectively). Oxytocin administration resort was superior in single balloon catheter group. There was no significant difference on others outcomes. Labor induction costs were 9euros in single balloon catheter group, versus 55 and 81 euros in double balloon catheter group and dinoprostone insert group respectively.

CONCLUSIONS

Single balloon catheter seems just as effective as double balloon catheter and dinoprostone insert with its major asset the low cost for labor induction.

Risk of maternal, fetal and neonatal complications associated with the use of the transcervical balloon catheter in induction of labour: A systematic review

Induction of labour is one of the most frequently applied obstetrical interventions globally. Many studies have compared the use of balloon catheters with pharmacological agents. Although the safety of the balloon catheter is often mentioned, little has been written about the total spectrum of maternal and fetal morbidity associated with induction of labour using a balloon catheter. We evaluated the safety of labour induction with a transcervical balloon catheter by conducting a literature review with pooled risk assessments of the maternal, fetal and neonatal morbidity. We searched Medline, EMBASE and CINAHL as well as the Cochrane database using the Keywords 'induction of labour', 'cervical ripening', 'transcervical balloon', 'balloon catheter' and 'Foley balloon'. We did not use language or date restrictions. Randomized and quasi-randomized controlled trials as well as observational studies that contained original data on occurrence of maternal, fetal or neonatal morbidity during induction of labour with the balloon catheter were included. Studies were excluded if the balloon catheter was used concurrently with oxytocin and concurrently or consecutively with misoprostol, dinoprostone or extra-amniotic saline infusion. Study selection and quality assessment was performed by two authors independently using a standardized critical appraisal instrument. Outcomes were reported as weighted mean rates. We detected 84 articles reporting on 13,791 women. The overall risk of developing intrapartum maternal infection was 11.3% (912 of 8079 women), 3.3% (151 of 4538 women) for postpartum maternal infection and 4.6% (203 of 4460 women) for neonatal infection. Uterine hypercontractility occurred in 2.7% (148 of 5439) of the women. Uterine rupture after previous caesarean section occurred in 1.9% of women (26 of 1373), while other major maternal complications had an occurrence rate of <1%. The risk for developing minor maternal complications was <2%. The risk of developing a non-reassuring fetal heart rate was 10.8% (793 of 7336 women), 10.1% (507 of 5008 women) for fetal distress and 14.0% (460 of 3295 women) for meconium stained liquor. Neonatal death occurred in 0.29% (6 of 2058) of the deliveries and NICU admission in 7.2% (650 of 9065 deliveries). This review shows that labour induction with a balloon catheter is a safe intervention, with intrapartum maternal infection being the only reasonable risk above 10%.

[Double-balloon catheter compared to vaginal dinoprostone for cervical ripening in obese women at term]

OBJECTIVE

To compare the efficacy of a double-balloon catheter versus vaginal prostaglandin E2 (dinoprostone) for cervical ripening in obese patients with unfavorable cervix at term.

METHODS

The study had an open-label, prospective combined with retrospective, observational design. From January 2013 until May 2016, a prospective cohort study of 46 women with pre-pregnancy BMI>30kg/m², live singleton term fetuses (>37 weeks) in vertex presentation and unfavorable cervix (Bishop score<6), who underwent labor induction for conventional indications using a double-balloon catheter. In the same period, 46 obese women who had undergone cervical ripening using vaginal dinoprostone (3mg) were retrospectively included. Women in groups were paired according to Bishop score before the insertion, pre-pregnancy BMI and parity. The primary outcome was a favorable cervix (Bishop score ≥6) 24h after cervical ripening.

RESULTS

After 24h, there was a significantly higher rate of women with favorable cervix (Bishop score ≥6) in the double-balloon group than in dinoprostone group (80.4% vs 47.8%; P=0.001). After adjustment, a double-balloon catheter was significantly associated with an efficient cervical ripening compared to vaginal dinoprostone (aOR 7.81, 95% CI 2.58-23.60). No difference was observed in cesarean section rate (39.1% in each group; P=0.96) and in mean induction time to vaginal delivery (34.5h in the balloon group vs 36.5h in the dinoprostone group; P=0.53). Maternal and neonatal outcomes were similar.

CONCLUSION

For obese patients at term, cervical ripening using a double-balloon catheter is more efficient on Bishop score after 24h compared to vaginal dinoprostone.

A comparison of induction of labor success rates over three time periods in 20 years at a single academic tertiary care center: are we improving vaginal delivery rates?

OBJECTIVE

To compare the rates of successful induction of labor during three one-year periods over 20 years at a single institution.

METHODS

All women at 37 weeks or beyond with a living, singleton, cephalic fetus admitted for induction of labor in 1992, 2002, and 2012 were included. The use of induction agents and rates of successful vaginal delivery were compared.

RESULTS

A total of 627 women were evaluated, 219 in 1992, 220 in 2002, and 188 in 2012. Various induction agents were employed over the 20 year period. However, the rates of successful vaginal deliveries did not significantly vary over the three time periods, 79.5% in 1992, 72.3% in 2002, 76.1% in 2012, p = .21. In subgroup analysis, no significant differences were found among women with one or more prior vaginal delivery, no prior vaginal delivery, or after excluding those with a prior cesarean section. In multiple variable logistic regression analysis, no induction agent besides amniotomy improved successful vaginal delivery rates.

CONCLUSIONS

Despite the multiple induction agents available at our tertiary care institution over the past 20 years, we were unable to demonstrate any significant improvement in successful vaginal delivery rates after induction of labor.

[Clinical efficacy and safety of controlled-release dinoprostone insert: a multicenter retrospective study]

OBJECTIVE

To analyze the effectiveness and safety of controlled-release dinoprostone insert for term labor induction in the Pearl River Delta of Guangdong province.

METHODS

Twenty hospitals using controlled-release dinoprostone insert for term labor induction in the Pearl River Delta of Guangdong province were stratified into provincial hospitals and municipal hospitals, and three hospitals of each level were selected as research units. According to the inclusion and exclusion criteria, 1390 pregnant women receiving term labor induction using controlled-release dinoprostone insert were retrospectively analyzed to evaluate the the effectiveness and safety with another 957 pregnant women with induced abortion using oxytocin as the control group.

RESULTS

Compared with the control group, the controlled-release dinoprostone insert group showed a significantly longer length of the latent phase of labor (4.06∓2.65 vs 3.20∓2.08 h, P=0.003, 95%CI [0.182, 0.920]) and shorter lengths of the active phase (1.73∓1.32 vs 2.22∓1.75 h, P=0.000, 95%CI [-0.795, -0.363]) and the second stage of labor (0.49∓0.37 vs 0.54∓0.43 h, P=0.003, 95%CI [-0.137, -0.028]). No significant differences were found in the length of the first stage of labor, the vaginal delivery rate, adverse reactions, or fetal outcomes between the two groups.

CONCLUSION

Controlled-release dinoprostone insert is effective and safe for labor induction at term.

Tension compared to no tension on a Foley transcervical catheter for cervical ripening: a randomized controlled trial

BACKGROUND

Cervical ripening of an unfavorable cervix can be achieved by placement of a transcervical catheter. Advantages of this method include both lower cost and lower risk of tachysystole than other methods. Despite widespread use with varying degrees of applied tension, an unanswered question is whether there is an advantage to placing the transcervical catheter to tension compared with placement without tension.

OBJECTIVE

The purpose of this study was to determine whether tension placed on a transcervical balloon catheter that is inserted for cervical ripening results in a faster time to delivery.

STUDY DESIGN

This was a prospective, randomized controlled trial; 140 women who underwent cervical ripening (Bishop score, ≤6) were assigned randomly to a balloon catheter with applied tension vs no tension. Tension was created when the catheter was taped to the patient's thigh and tension was reapplied in 30-minute increments. There were 67 patients in the tension group and 73 patients in the no tension group. Low-dose oxytocin (maximum, 6 mU/min) was administered after catheter placement. The primary outcome was time from catheter insertion to delivery. A secondary outcome was time from insertion to catheter expulsion. The Kolmogorov-Smirnov test was used to determine whether the data were distributed normally. Survival curves that used lifetables were constructed from time of catheter insertion to delivery and from time of catheter insertion to catheter expulsion and were compared with the use of the Wilcoxon (Gehan) Breslow statistic. A probability value of <.05 was set to denote statistical significance.

RESULTS

Baseline characteristics were similar between groups. The median time from catheter insertion to delivery was not significantly different between the tension group and the no tension group (16.2 vs 16.9 hours; P=.814). The median time from catheter insertion to expulsion, however, was significantly less in the tension group vs the no tension group (2.6 vs 4.6 hours; P<.001), respectively. Vaginal delivery within 24 hours was not significantly different between the tension and no tension groups (41/52 [79%] vs 37/52 [71%]; P=.365) nor were there significant differences in cesarean delivery rates between the tension and no tension groups (17/67 [25%] vs 27/73 [37%]; P=.139).

CONCLUSION

Application of tension did not result in faster delivery times but did result in faster times to catheter expulsion.

Misoprostol Vaginal Insert in Labor Induction: A Cost-Consequences Model for 5 European Countries-An Economic Evaluation Supported with Literature Review and Retrospective Data Collection

Introduction

The present study aimed to assess the costs and consequences of using an innovative medical technology, misoprostol vaginal insert (MVI), for the induction of labor (IOL), in place of alternative technologies used as a standard of care.

Methods

This was a retrospective study on cost and resource utilization connected with economic model development. Target population were women with an unfavorable cervix, from 36 weeks of gestation, for whom IOL is clinically indicated. Data on costs and resources was gathered via a dedicated questionnaire, delivered to clinical experts in five EU countries. The five countries participating in the project and providing completed questionnaires were Austria, Poland, Romania, Russia and Slovakia. A targeted literature review in Medline and Cochrane was conducted to identify randomized clinical trials meeting inclusion criteria and to obtain relative effectiveness data on MVI and the alternative technologies. A hospital perspective was considered as most relevant for the study. The economic model was developed to connect data on clinical effectiveness and safety from randomized clinical trials with real life data from local clinical practice.

Results

The use of MVI in most scenarios was related to a reduced consumption of hospital staff time and reduced length of patients’ stay in hospital wards, leading to lower total costs with MVI when compared to local comparators.

Conclusions

IOL with the use of MVI generated savings from a hospital perspective in most countries and scenarios, in comparison to alternative technologies.

Funding

Sponsorship, article processing charges, and the open access charge for this study were funded by Ferring Pharmaceuticals Poland.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-016-0397-3) contains supplementary material, which is available to authorized users.

Foley catheter for induction of labor: potential barriers to adopting the technique

OBJECTIVE

To evaluate if a learning curve exists for cervical Foley placement for labor induction in women with unfavorable cervices and whether labor curves differ compared with the dinoprostone insert (PGE2).

STUDY DESIGN

We conducted a secondary analysis of a multicenter randomized controlled trial.

RESULT

For Foley and PGE2, successful placement occurred in 157/185 (85%) and 188/191 (98%) women (P<0.001). Unsuccessful Foley placements decreased over time (P=0.005); all occurred at the site previously using PGE2 preferentially. In women with allocated agent placed successfully who achieved complete cervical dilation, median progress with Foley (n=112), compared with PGE2 (n=123), was: 1-3 cm (6.2 vs 14.1 h; P<0.001), 3-6 cm (11.1 vs 6.7 h; P<0.001) and 6-10 cm (1.9 vs 1.5 h; P=0.14).

CONCLUSION

There is a learning curve for placing cervical Foley catheters. Despite faster times to delivery, Foley is associated with slower dilation from 3 to 6 cm compared with PGE2.

Planned cesarean delivery compared to induction of labor in women with class III obesity: a cost-minimization analysis (.)

OBJECTIVE

To compare the costs between planned cesarean delivery (CD) and induction of labor (IOL) in women with class III obesity.

METHODS

We conducted a cost-minimization analysis using data from a previous study of women with a BMI ≥40 kg/m(2) delivering term singletons via planned CD or after IOL. Decision trees were built with branches for two "treatments": planned CD and IOL (probabilities derived from parent study). Direct and total costs were obtained for each mother-infant pair. Sensitivity analyses for probability of successful IOL were performed.

RESULTS

A total of 661 mother-infant pairs were included - 399 IOLs and 262 planned CDs. Of 399 IOLs, 236 (59%) delivered vaginally and 163 (41%) had a CD. IOL was slightly less costly. For IOL and planned CD, respectively, direct costs were $7416 versus $7474, and total costs were $11 545 versus $11 665. Sensitivity analyses indicated that IOL was the least costly strategy if the probability of vaginal delivery after IOL was >57% (0.575 for direct costs; 0.570 for total costs). There was, however, a slight cost advantage to planned CD in women with a prior cesarean.

CONCLUSIONS

In women with class III obesity, IOL is less costly than planned CD if the probability of vaginal delivery after IOL in an individual patient is greater than 57%.

Controlled-release dinoprostone insert versus Foley catheter for labor induction: a meta-analysis

OBJECTIVE

To compare the effectiveness and safety of controlled-release dinoprostone insert with Foley catheter balloon for cervical ripening and labor induction.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and China Knowledge Resource Integrated Database were searched. Only randomized controlled trials comparing controlled-release dinoprostone insert with Foley catheter balloon were included. Risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) was calculated.

RESULTS

Six studies were included with 731 women received dinoprostone insert and 722 Foley catheter. Time from induction to delivery was significantly shortened in dinoprostone insert group compared to Foley catheter group (MD 5.73 h, 95% CI 1.26-10.20). There were no significant differences in vaginal delivery within 24 h (RR 0.75, 95% CI 0.43-1.30) or cesarean section (RR 0.94, 95% CI 0.80-1.12) between two ripening methods. Dinoprostone insert was related with increased rate of excessive uterine contraction (RR 0.07, 95% CI 0.03-0.19), but less oxytocin use (RR 1.86, 95% CI 1.25-2.77) when compared with Foley catheter.

CONCLUSIONS

Induction of labor with controlled-release dinoprostone insert seems to be more effective than Foley catheter. However, the former method causes excessive uterine contraction more frequently.

Failed induction of labor

Induction of labor will affect almost a quarter of all pregnancies, but historically there has been no generally accepted definition of failed induction of labor. Only recently have studies analyzed the lengths of latent labor that are associated with successful labor induction ending in a vaginal delivery, and recommendations for uniformity in the diagnosis of failed induction have largely resulted from this data. This review assesses the most recent and inclusive definition for failed induction, risk factors associated with failure, complications, and special populations that may be at risk for a failed induction.

A randomised controlled study comparing valethamate bromide and placebo in shortening the duration of active labour

The aim of this study is to compare the efficacy and safety of valethamate bromide and placebo against placebo in shortening the duration of active labour. A prospective randomised trial of 158 low-risk women in spontaneous labour was conducted. After evaluation of the patients according to exclusion criteria 30 women were given valethamate bromide (Group 1) and 32 women were given placebo (Group 2). Labour duration was the main outcome measure. The duration of the active phase after starting the treatment was similar in the two groups at 225 and 219 min, respectively. However, differences were not significant between the 2 groups. Side effects such as tachycardia, flushing of the face and dryness of mouth were noted with valethamate bromide administration. In conclusion, valethamate bromide did not significantly shortened the duration of active labour in nulliparous women with a singleton pregnancy at term.