Mechanical and Pharmacologic Methods of Labor Induction: A Randomized Controlled Trial

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

BACKGROUND

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

OBJECTIVE

To compare the effectiveness and safety of dinoprostone versus transcervical Foley catheter for induction of labor 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 induction of labor were eligible. 1,860 women were randomly allocated to cervical ripening with either a dinoprostone vaginal insert (10mg) or a 60cc 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% CI 0.98 to 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 to 1.88), while more neonatal asphyxia occurred in the dinoprostone group (1.2% vs. 0.2%, aRR 5.39, 95% CI 1.22 to 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 to 0.99).

CONCLUSIONS

In term pregnant women with an unfavorable cervix, induction of labor 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.

Predictive Factors for the Success of Vaginal Dinoprostone for the Induction of Labour

Objective

To evaluate factors predictive of the success of a slow-release dinoprostone vaginal insert for cervical ripening.

Methods

This retrospective study included 187 women who received dinoprostone vaginal inserts for cervical ripening. The participants were divided into two groups: the transvaginal delivery group (n = 87) and cesarean section termination group (n = 100). The correlation between the parameters present before cervical ripening with dinoprostone slow release and its success, as well as complications and adverse outcomes, was analyzed. Cesarean section predictors and area under the curve (AUC) were compared between the two Groups.

Results

There were statistical differences between the two groups in body mass index (BMI), height, cervical Bishop score, cephalic position, time of medication use, and fetal head position at the time of medication use (P<0.05). The optimal thresholds for identifying cesarean section in dinoprostone vaginal insert for cervical ripening were 162.5 for height (AUC = 0.61), 10.65 cm for amniotic fluid index (AUC = 0.6), S-2.5 for cephalic position (AUC = 0.61), 5.5 for bishop score of cervix (AUC = 0.65). The height, amniotic fluid index, cephalic position, and Bishop score of the cervix were included in the same model. The AUC value of the combined model was higher than the AUC value of the single factor.

Conclusion

The combined model was a better predictor of cesarean section in dinoprostone vaginal inserts for cervical ripening and labor induction. The success of cervical ripening with a dinoprostone slow-release vaginal insert can be predicted by the factors that can be recognized at admission.

Effect of Vaginal Washing before Intravaginal Prostaglandin Insertion on Induction of Labor: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

Saline vaginal douching prior to intravaginal prostaglandin application might increase the vaginal pH, leading to improvement of prostaglandin bioavailability, by which the outcomes of labor induction can be greatly improved. Thus, we aimed to evaluate the effect of vaginal washing with normal saline before insertion of vaginal prostaglandin for labor induction.

STUDY DESIGN

A systematic search was done in PubMed, Cochrane Library, Scopus, and ISI Web of Science from inception to March 2022. We selected randomized controlled trials (RCTs) that compared vaginal washing using normal saline versus no vaginal washing in the control group before intravaginal prostaglandin insertion during labor induction. We used RevMan software for our meta-analysis. Our main outcomes were the duration of intravaginal prostaglandin application, duration from intravaginal prostaglandin insertion to active phase of labor, duration from intravaginal prostaglandin insertion till total cervical dilatation, labor induction failure rate, incidence of cesarean section (CS), and rates of neonatal intensive care unit (NICU) admission and fetal infection postdelivery.

RESULTS

Five RCTs were retrieved with a total number of 842 patients. Duration of prostaglandin application, duration from prostaglandin insertion to active phase of labor, and time interval from prostaglandin insertion to total cervical dilatation were significantly shorter among vaginal washing group (p < 0.05). Vaginal douching prior to prostaglandin insertion significantly decreased the incidence of failed labor induction (p < 0.001). After the removal of reported heterogeneity, vaginal washing was linked to a significant decline in CS incidence (p = 0.04). In addition, the rates of NICU admission and fetal infection were significantly lower in the vaginal washing group (p < 0.001).

CONCLUSION

Vaginal washing with normal saline before intravaginal prostaglandin insertion is a useful and easily applicable method for labor induction with good outcomes.

KEY POINTS

· Induction of labor is frequently used in the obstetrics field.. · We assessed vaginal washing impact before prostaglandin insertion for labor induction.. · Vaginal washing is an easily applicable method for labor induction with good outcomes..

Buccal Versus Vaginal Misoprostol Combined with a Foley Catheter among Individuals with Obesity Undergoing Induction

BACKGROUND

 Combining pharmacologic agents with mechanical ripening achieves the shortest labor duration, yet there is no clear evidence on route of drug administration in obese individuals. The use of buccal misoprostol has shown greater patient acceptance but remains understudied.

OBJECTIVE

 Our objective was to evaluate the difference in time to delivery of buccal compared with vaginal misoprostol in combination with a Foley catheter (FC) for induction of labor (IOL) in the obese population.

STUDY DESIGN

 This was a secondary analysis of a randomized controlled trial comparing identical dosages (25 μg) of buccal and vaginal misoprostol in combination with a FC. The parent trial was an institutional review board-approved, randomized clinical trial conducted from June 2019 through January 2020. Labor management was standardized among participants. Women undergoing IOL at ≥37 weeks with a singleton gestation and cervical dilation ≤2 cm were included. Body mass index (BMI, kg/m2) was stratified. The primary outcome was time to delivery.

RESULTS

 A total of 215 participants were included. Demographic characteristics were similar between the three groups. Vaginal drug administration achieved a faster median time to delivery than the buccal route among patients with a body mass index greater than or equal to 30 kg/m2 (vaginal misoprostol-FC: 21.3 hours vs. buccal misoprostol-FC: 25.2 hours, p = 0.006). There was no difference in the cesarean delivery rate between the two groups. Furthermore, patients with a BMI greater than or equal to 30 kg/m2 receiving vaginal misoprostol delivered 1.2 times faster than women who received buccal misoprostol after censoring for cesarean delivery and adjusting for parity (hazard ratio: 1.2, 95% confidence interval: 1.1-1.7). There were no significant differences in maternal and neonatal outcomes.

CONCLUSION

 We found that vaginal misoprostol was superior to buccal misoprostol when combined with a FC among individuals with a BMI greater than or equal to 30 kg/m2. Vaginal misoprostol should be the preferred route of drug administration for term IOL in this population.

KEY POINTS

· Vaginal misoprostol was superior to buccal route among patients with obesity.. · There was no difference in the cesarean delivery rate between the two groups.. · Vaginal misoprostol should be the preferred route of administration among patients with obesity..

Implementation and Clinical Impact of a Guideline for Standardized, Evidence-Based Induction of Labor

OBJECTIVE

 This study aimed to assess the impact of implementation of an induction of labor (IOL) guideline on IOL length and utilization of evidence-based practices.

STUDY DESIGN

 We conducted a quality improvement project to increase utilization of three evidence-based IOL practices: combined agent ripening, vaginal misoprostol, and early amniotomy. Singletons with intact membranes and cervical dilation ≤2 cm admitted for IOL were included. Primary outcome was IOL length. Secondary outcomes included cesarean delivery and practice utilization. We compared preimplementation (PRE; November 1, 2021 through January 31, 2022) to postimplementation (POST; March 1, 2022 through April 30, 2022) with sensitivity analyses by self-reported race and ethnicity. Cox proportional hazards models and logistic regression were used to test the association between period and outcomes.

RESULTS

 Among 495 birthing people (PRE, n = 293; POST, n = 202), IOL length was shorter POST (22.0 vs. 18.3 h, p = 0.003), with faster time to delivery (adjusted hazard ratio [aHR] 1.38, 95% CI 1.15-1.66), more birthing people delivered within 24 hours (57 vs. 68.8%, adjusted odds ratio [aOR] 1.90 [95% CI 1.25-2.89]), and no difference in cesarean. Utilization of combined agent ripening (31.1 vs. 42.6%, p = 0.009), vaginal misoprostol (34.5 vs. 68.3%, p < 0.001), and early amniotomy (19.1 vs. 31.7%, p = 0.001) increased POST.

CONCLUSION

 Implementation of an evidence-based IOL guideline is associated with shorter induction time. Additional implementation efforts to increase adoption of practices are needed to optimize outcomes after IOL.

KEY POINTS

· Implementation of an IOL guideline is associated with faster time to delivery.. · Evidence-based induction practices were used more often after guideline implementation.. · Adoption of evidence-based induction practices is variable even with a guideline..

Combination Foley Catheter-Oxytocin versus Oxytocin Alone following Preterm Premature Rupture of Membranes

OBJECTIVE

 The benefit of mechanical ripening agents following preterm premature rupture of membranes (PPROM) has not been established. We sought to compare the time to delivery in women who received transcervical Foley catheter plus oxytocin infusion versus oxytocin infusion alone in patients with unfavorable cervices and PPROM.

STUDY DESIGN

 This is a retrospective cohort study of patients presenting with PPROM of a live, singleton gestation between 240/7 and 366/7 weeks' gestation from January 2005 to October 2018 at a single, tertiary care institution. Patients with an unfavorable cervical examination (≤2-cm dilation), no contraindication to labor and undergoing labor induction were analyzed. Time to delivery was analyzed using multivariable linear regression adjusting for cervical dilation at induction and nulliparity. Bivariate and multivariate analyses were used where appropriate.

RESULTS

 A total of 260 participants were included: 109 who received a Foley catheter and oxytocin (Foley/oxytocin) and 151 who had oxytocin alone. Demographic characteristics were similar between the two groups. Unadjusted time to delivery was significantly shorter in the oxytocin only group (Foley/oxytocin: 20.35 hours vs. oxytocin alone: 14.7 hours, p < 0.001). No differences in length of labor were detected after adjusting for cervical dilation at induction and nulliparity (p = 0.5). The unadjusted rate of cesarean delivery was higher in the combination Foley/oxytocin group (Foley/oxytocin: 16.5% vs. oxytocin alone: 7.3%, p = 0.03), but no differences were found in the adjusted analysis (p = 0.06). There were no differences in clinical chorioamnionitis rates between the two groups (Foley/oxytocin: 8.3% vs. oxytocin alone: 9.3%, p = 0.83). Furthermore, no significant differences were found in maternal and neonatal outcomes between the two groups.

CONCLUSION

 In patients with PROM, the use of a transcervical Foley catheter in addition to oxytocin is not associated with a shorter time to delivery compared with oxytocin alone.

KEY POINTS

· Transcervical Foley catheter did not shorten length of labor in PPROM.. · Transcervical Foley catheter did not increase infection risk.. · Pitocin alone can be used in PPROM population..

Applying Tension to the Transcervical Foley Balloon and Delivery Times in Term Nulliparous Women Undergoing Induction of Labor: A Randomized Controlled Trial

OBJECTIVE

To investigate the effects of applying tension to a transcervical Foley balloon on delivery time in term nulliparous patients undergoing labor induction.

METHODS

This cluster randomized clinical trial included 279 term nulliparous women presenting for labor induction with a plan for cervical ripening through transcervical Foley balloon placement. Participants were assigned to either the tension group (n=138) or the no-tension group (n=141) on the basis of randomized, weekly clusters (26 total clusters). The primary outcome measured was the time from initial Foley balloon insertion to delivery. Secondary outcomes included cesarean delivery rates, peripartum infection, and neonatal intensive care unit (NICU) admission. Our prior data suggested that delivery time in the tension group would be about 1,053 minutes. We estimated a sample size of 260 (130 per group, 26 clusters) on the basis of a 25% difference, power of 80%, and two-sided α of 0.05.

RESULTS

A total of 279 term nulliparous patients were included in the analysis. The median time from Foley placement to delivery was 1,596 minutes (range 430-3,438 minutes) for the tension group and 1,621 minutes (range 488-3,323 minutes) for the no-tension group ( P =.8); similar results were noted for time to vaginal delivery. No significant differences were observed in the secondary outcomes, including the rates of cesarean delivery (34.1% vs 29.8%, P =.7), peripartum infection, and NICU admission, between the two groups.

CONCLUSION

Applying tension to a transcervical Foley balloon in term nulliparous women undergoing labor induction did not significantly reduce delivery time or improve secondary outcomes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT05404776.

Optimal misoprostol dosing among patients with a body mass index greater than 30: a randomized controlled trial

BACKGROUND

Patients with obesity experience an increased duration of labor with an increased risk for perinatal morbidity. When compared with parturients without obesity, they also experience fewer uterine contractions after administration of misoprostol. It is unclear if the same dose of misoprostol should be used for induction of labor in patients with obesity compared to non-obese patients. Therefore, we sought to investigate if a higher dose of misoprostol for patients with obesity is more effective.

OBJECTIVE

This study aimed to determine if 50 μg compared with 25 μg of vaginal misoprostol reduced the time from induction start to delivery among patients with obesity.

STUDY DESIGN

We performed a double-blinded, pragmatic randomized controlled trial, between June 1, 2022, and July 17, 2023. Patients with a body mass index ≥30 kg/m2 who underwent labor induction at ≥ 36 weeks' gestation, had a singleton gestation, and a cervical dilation ≤3 cm at admission were included. Patients were excluded if they had a contraindication to vaginal delivery or misoprostol administration. Patients were randomized to 25 or 50 μg of vaginal misoprostol, stratified by parity, body mass index <40 kg/m2 or ≥40 kg/m2, and provider intent to use mechanical dilation at the onset of labor induction. Usual labor management was followed at the discretion of the provider. The primary outcome was time from induction to delivery. A priori, we estimated that 90 subjects per group (N=180) were needed for an 85% power to detect a 3-hour difference between groups with a type I error of 5%. Analysis was by intention-to-treat. A 2-sample t test was used for the primary outcome, Cohen's d was used as a measure of effect, and P values were reported.

RESULTS

Of the 180 patients randomized, 88 were assigned to the 25 μg group and 92 were assigned to the 50 μg group. Of those, 96.1% of patients received the designated intervention. The baseline characteristics were similar between groups. No difference was found in the primary outcome of time to delivery (21.6 hours vs 18.6 hours; d=.28; 95% confidence interval, -0.02 to 0.57). In a planned subgroup analysis, multiparous patients delivered faster in the 50 μg group (15.2 hours vs 12.0 hours; d=.51; 95% confidence interval, 0.04-0.97). The risk for tachysystole associated with fetal heart tracing changes was rare overall (2.2%) and not significantly different between groups. No differences in maternal or neonatal adverse effects were observed.

CONCLUSION

Patients with obesity who underwent cervical ripening with 50 μg of vaginal misoprostol experienced a similar time to delivery when compared with those who received 25 μg of misoprostol. However, multiparous patients had a significantly reduced time to delivery when 50 μg was used. A higher dose of misoprostol may be a promising intervention for reducing time in labor, which warrants further study.

Interval between balloon removal and oxytocin administration in cervical ripening with double-balloon in singleton pregnancies: An observational study

OBJECTIVE

To analyze the influence of the resting interval after removal of a double-balloon for cervical ripening and oxytocin administration on the time to onset of active labor in singleton pregnancies.

METHODS

A retrospective cohort study of women who required a cervical ripening with double-balloon was conducted between January 2019 and December 2022. We collected data for cervical ripening balloon insertion and removal, oxytocin administration, suspicious or pathological cardiotocographic trace, mode of delivery, maternal and neonatal complications, neonatal outcomes. Proportional hazards model comparing resting interval between double-balloon cervical ripening removal and oxytocin administration.

RESULTS

A total of 403 singleton pregnancies were recruited and 213 pregnant women experienced a rest of 12 h between cervical balloon removal and oxytocin administration (resting group). Oxytocin was administered immediately after balloon removal in 190 women (non-resting group). Median insertion-to-active labor interval and insertion-to-delivery interval were significantly shorter in the non-resting group: 18.5 versus 24.0 h, HR 2.59 (CI 95%: 1.97-3.41) and 24.0 versus 29.0 h, HR 2.38 (CI 95%: 1.85-3.05) respectively. Bishop score change and mode of delivery between were similar in both groups. No differences in maternal nor neonatal complications between both groups were found.

CONCLUSIONS

Oxytocin administration immediately after removal of a double-balloon for cervical ripening compared with 12 h delayed interval resulted in a shortened time from insertion to active labor onset and to delivery interval without increasing maternal or neonatal adverse outcomes.

Association of Prostaglandin Use for Cervical Ripening with Mode of Delivery in Small for Gestational Age versus Non-Small for Gestational Age Neonates

OBJECTIVE

Prostaglandins (PGs) use for cervical ripening with small for gestational age (SGA) fetuses is controversial since it remains uncertain if use increases the chance of cesarean delivery (CD). We aimed to assess the association between PG use for cervical ripening and mode of delivery between SGA and appropriate for gestational age (AGA) neonates.

STUDY DESIGN

Secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b), a prospective observational cohort study of 10,038 nulliparas. We included women undergoing induction with nonanomalous fetuses in the cephalic presentation. Women with >2 cm cervical dilation or prior uterine scar were excluded. We assessed the association of PG use with CD among women with SGA and AGA neonates. SGA was defined as birth weight <10th percentile for gestational age and sex. Multivariable logistic regression was used to adjust for potential confounders and test for interaction. Secondary outcomes included adverse neonatal outcomes, indication for CD, maternal hemorrhage, and chorioamnionitis.

RESULTS

Among 2,353 women eligible, PGs were used in 54.8%, SGA occurred in 15.1%, and 35.0% had CD. The association between PG use and CD differed significantly (interaction p = 0.018) for SGA versus AGA neonates; CD occurred more often in SGA neonates exposed to PGs than not (35 vs. 22%, p = 0.009). PG use was not associated with CD among AGA neonates (36 vs. 36%, p = 0.8). This effect remained significant when adjusting for body mass index, race/ethnicity, and cervical dilation. Among SGA neonates, CD for "nonreassuring fetal status" was similar between PG groups. Among SGA neonates, PG use was not associated with adverse neonatal outcomes or postpartum hemorrhage but had a higher rate of chorioamnionitis (7.0 vs. 2.1%, p = 0.048).

CONCLUSION

PG use was associated with a higher rate of CD in SGA but not AGA neonates; however, further studies are needed before PG use is discouraged with SGA neonates.

KEY POINTS

· PGs are commonly used for cervical ripening.. · PG use was associated with increased risk of cesarean delivery in SGA neonates.. · PG use was not associated with adverse neonatal outcomes..

Peripartum Pharmacotherapy: A Pharmacist's Guide

Complications throughout the peripartum period may be caused by preexisting conditions or pregnancy-induced conditions and may alter pharmacotherapy management. Pharmacotherapy management during late pregnancy and delivery requires careful consideration due to changing hormones, hemodynamic status, and pharmacokinetics, and concerns for potential maternal and/or fetal morbidity. Increased maternal and fetal monitoring are often required and may lead to therapy changes. Pharmacists, as key members of the interprofessional team, can contribute essential perspective to the management of postpartum pharmacotherapy through assessment and recommendation of appropriate and judicious use of medications.

Comparison of digital and speculum-guided methods of transcervical Foley catheter insertion in primigravida undergoing cervical ripening at term gestation: a noninferiority randomized clinical trial

BACKGROUND

Foley catheter insertion is frequently used for cervical ripening during the induction of labor. However, the insertion failure, safety, maternal side effects, complications, and satisfaction of digital compared with speculum-guided Foley catheter placement have not been evaluated in a large trial involving primigravida.

OBJECTIVE

The study aimed to compare the insertion failure rate of digital and speculum-based transcervical Foley catheter placement in primigravida. The co-primary outcome was insertion-associated pain. The secondary outcomes were the time required for successful insertion, maternal satisfaction, and maternal complications within 24 hours of Foley insertion.

STUDY DESIGN

This randomized, open-label, parallel-arm, noninferiority clinical trial was performed in a large tertiary care university hospital. Primigravida aged >18 years with term gestation (≥37 weeks) were included in this study. Additional inclusion criteria for enrollment in this study were singleton pregnancy with a cephalic presentation, intact membrane, a Bishop score of ≤5, and reassuring preinduction fetal heart rate tracing. All women planned for cervical ripening were assessed for eligibility and were randomized into digital or speculum arms. Foley catheter insertion was performed in a supine lithotomy position. Vaginal and cervical cleaning were performed before insertion. A 22-French Foley balloon catheter was guided digitally or via speculum to position the bulb at the level of the internal os using water-soluble lubricant. Insertion-associated pain was measured using a visual numeric rating scale, and maternal satisfaction was assessed using a set of questions.

RESULTS

Four hundred and sixty-nine pregnant women were assessed for eligibility, and 446 patients were enrolled and randomized. The median age of the parturients was 24 (19-40) and 24 (18-38) years, respectively. The body mass index, gestational age at randomization, the incidence of postdated pregnancy, and prerandomization Bishop scores were comparable. Insertion failure was observed in 24 (10.8%) and 17 (7.6%) women in digital and speculum arms, respectively (relative risk=1.41 [95% confidence interval, 0.78-2.55]; P=.25). Requirements of >1 attempt (5.4% vs 3.6%) followed by the change in hands (3.6% vs 2.7%) were the most common reasons for insertion failure. The median (interquartile range) visual numeric rating scale was comparable (6 [2-9] vs 5 [2-10]; P=.15). The time taken for successful insertion was similar (58 [12-241] vs 54 [10-281]; P=.30). 9.4% and 10.8% of women required additional methods of cervical ripening. More women in the speculum group (41.7% vs 33.2%; P=.06) felt a medium level of discomfort than the digital group.

CONCLUSION

Insertion failure and insertion-related pain in the digital approach were comparable to the speculum-guided approach for transcervical Foley catheter insertion in primigravida for cervical ripening. Nevertheless, maternal satisfaction was higher in the digital group because of a lesser level of discomfort.

Randomized control trial comparing hygroscopic cervical dilators to cervical ripening balloon for outpatient cervical ripening

BACKGROUND

Outpatient term preinduction cervical ripening with mechanical agents has been associated with reduced length of stay, decreased cesarean delivery rates, low maternal and neonatal complications, and increased incidence of vaginal delivery within 24 hours.

OBJECTIVE

This study aimed to demonstrate equivalent efficacy between synthetic hygroscopic dilators and the single-balloon catheter for outpatient cervical ripening.

STUDY DESIGN

This randomized control equivalence trial compared synthetic hygroscopic dilators with the 30-mL silicone single-balloon catheter in primiparous and multiparous patients undergoing labor induction. The primary outcome was time from admission to delivery, with a prespecified 3-hour margin of equivalence. The secondary objectives were patient outcomes and perspectives.

RESULTS

Between March 1, 2019, and May 31, 2021, 1605 patients met the screening criteria, and 174 patients completed the study. The mean admission-to-delivery time was equivalent at 18.01 hours for the dilator group vs 17.55 hours for the balloon group (P=.04). The cesarean delivery rate of primiparous patients was similar at 28.1% with dilators vs 29.7% with the balloon. The groups had similar median cervical dilation and pain scores on insertion and admission. Overall patient satisfaction was high, 92.8% with dilators vs 96.2% with the balloon. The balloon group had significantly higher rates of early admission and device expulsion.

CONCLUSION

Although the enrollment goal was not met, our study suggests that synthetic hygroscopic dilators and the single-balloon catheter for outpatient cervical ripening are both efficacious with similar time from admission to delivery, pain scores, and patient satisfaction with the procedure.

Outpatient cervical ripening and labor induction with low-dose vaginal misoprostol reduces the interval to delivery: a systematic review and network meta-analysis

OBJECTIVE

Several systematic reviews and meta-analyses have summarized the evidence on the efficacy and safety of various outpatient cervical ripening methods. However, the method with the highest efficacy and safety profile has not been determined conclusively. We performed a systematic review and network meta-analysis of published randomized controlled trials to assess the efficacy and safety of cervical ripening methods currently employed in the outpatient setting.

DATA SOURCES

With the assistance of an experienced medical librarian, we performed a systematic search of the literature using MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and ClinicalTrials.gov. We systematically searched electronic databases from inception to January 14, 2020.

STUDY ELIGIBILITY CRITERIA

We considered randomized controlled trials comparing a variety of methods for outpatient cervical ripening.

METHODS

We conducted a frequentist random effects network meta-analysis employing data from randomized controlled trials. We performed a direct, pairwise meta-analysis to compare the efficacy of various outpatient cervical ripening methods, including placebo. We employed ranking strategies to determine the most efficacious method using the surface under the cumulative ranking curve; a higher surface under the cumulative ranking curve value implied a more efficacious method. We assessed the following outcomes: time from intervention to delivery, cesarean delivery rates, changes in the Bishop score, need for additional ripening methods, incidence of Apgar scores <7 at 5 minutes, and uterine hyperstimulation.

RESULTS

We included data from 42 randomized controlled trials including 6093 participants. When assessing the efficacy of all methods, 25 μg vaginal misoprostol was the most efficacious in reducing the time from intervention to delivery (surface under the cumulative ranking curve of 1.0) without increasing the odds of cesarean delivery, the need for additional ripening methods, the incidence of a low Apgar score, or uterine hyperstimulation. Acupressure (surface under the cumulative ranking curve of 0.3) and primrose oil (surface under the cumulative ranking curve of 0.2) were the least effective methods in reducing the time to delivery interval. Among effective methods, 50 mg oral mifepristone was associated with the lowest odds of cesarean delivery (surface under the cumulative ranking curve of 0.9).

CONCLUSION

When balancing efficacy and safety, vaginal misoprostol 25 μg represents the best method for outpatient cervical ripening.

Methods for the induction of labor: efficacy and safety

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.

Cesarean section rate: navigating the gap between WHO recommended range and current obstetrical challenges

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.

Association between intrapartum antibiotic prophylaxis for Group B Streptococcus colonization and clinical chorioamnionitis among patients undergoing induction of labor at term

BACKGROUND

Rectovaginal colonization with Group B Streptococcus during pregnancy has historically been shown to be associated with an increased risk of clinical chorioamnionitis and peripartum infectious morbidity.

OBJECTIVE

Newer observational data in the era of intrapartum antibiotic prophylaxis suggest a possible reversal of this association; however, it is unclear if this is related to differences in labor management for those with and without Group B Streptococcus colonization. We therefore sought to assess the association between intrapartum antibiotic prophylaxis for Group B Streptococcus colonization and clinical chorioamnionitis within the context of a randomized induction of labor trial with a standardized labor protocol.

STUDY DESIGN

We performed an exploratory secondary analysis of a randomized trial of patients undergoing term induction at a tertiary care center. Patients received third trimester Group B Streptococcus screening and intrapartum antibiotic prophylaxis as routine care. Group B Streptococcus detection was performed using a carrot broth-enhanced subculture to Group B Streptococcus Detect approach (Hardy Diagnostics, Santa Maria, CA). Labor management was protocolized per the trial. Patients with unknown Group B Streptococcus status or who did not receive intrapartum antibiotic prophylaxis, if indicated, were excluded. The primary outcome was diagnosis of clinical chorioamnionitis, compared between patients who received intrapartum antibiotic prophylaxis for known Group B Streptococcus positive status (by culture, history, or Group B Streptococcus bacteriuria) and those who were Group B Streptococcus negative and did not receive intrapartum antibiotic prophylaxis. Secondary outcomes included postpartum endometritis, wound infection, a composite maternal peripartum infectious morbidity, and neonatal outcomes.

RESULTS

A total of 491 patients were enrolled in the trial. Of these, 466 had a known Group B Streptococcus status and received or did not receive intrapartum antibiotic prophylaxis accordingly and were included in this analysis: 292 (62.7%) were Group B Streptococcus negative and did not receive intrapartum antibiotic prophylaxis, and 174 (37.3%) were Group B Streptococcus positive and received intrapartum antibiotic prophylaxis. The majority of patients were Non-Hispanic Black (78.1%) and nulliparous (59.7%). There were no differences in demographic, clinical, induction or labor characteristics between groups. Patients who were Group B Streptococcus positive had a 49% lower rate of clinical chorioamnionitis (8.1% vs 14.7%, odds ratio, 0.51; P=.03) and a lower rate of peripartum infectious morbidity (8.1% vs 15.8%, odds ratio, 0.47; P=.02) compared to those who were Group B Streptococcus negative. Infants born to patients who were Group B Streptococcus positive were significantly less likely to be admitted to the neonatal intensive care unit (3.4% vs 15.1%, P<.001).

CONCLUSION

Although Group B Streptococcus colonization has historically been considered a risk factor for clinical chorioamnionitis, in the era of universal antibiotic prophylaxis for Group B Streptococcus positive patients, our findings support the point that intrapartum antibiotic prophylaxis for Group B Streptococcus positivity is associated with lower rates of clinical chorioamnionitis and peripartum infectious morbidity among patients undergoing induction with protocolized labor management. These findings demonstrate that intrapartum antibiotic prophylaxis for Group B Streptococcus may protect against perinatal infectious morbidity, a phenomenon that warrants further investigation.

Association between intracervical Foley balloon and clinical chorioamnionitis among patients with group B streptococcus colonization undergoing induction with standardized labor management

BACKGROUND

Intracervical Foley balloons are commonly used for cervical ripening, but there has been a historical concern regarding an increased risk of clinical chorioamnionitis with Foley balloon use in patients with group B streptococcus.

OBJECTIVE

This study aimed to determine whether intracervical Foley balloon use in patients with group B streptococcus is associated with an increased risk of clinical chorioamnionitis.

STUDY DESIGN

This was a secondary analysis of a randomized controlled trial Mechanical and Pharmacologic Methods of Labor Induction: A Randomized Controlled Trial that compared cervical ripening agents within a standardized labor protocol. Foley balloon (alone, with oxytocin, or with misoprostol) was compared with misoprostol only to evaluate the primary outcome of clinical chorioamnionitis, defined based on the American College of Obstetricians and Gynecologists guidelines. Patients with a term, singleton pregnancy with intact membranes and an unfavorable cervix (Bishop score of ≤6 and dilation ≤2 cm) and a known group B streptococcus status were included. The secondary outcomes included a composite postpartum maternal infectious outcome consisting of any occurrence of endometritis, wound infection, postpartum urinary tract infection, or maternal sepsis; additional secondary outcomes included neonatal outcomes. Binomial regression with robust error variance was used to evaluate whether group B streptococcus status modified the relationship between Foley balloon use and clinical chorioamnionitis and to adjust for confounders.

RESULTS

A total of 491 patients were enrolled in the original trial. Of these patients, 467 had a known group B streptococcus status and underwent cervical ripening: 182 (39.0%) had group B streptococcus, and 285 (61.0%) did not have group B streptococcus. Moreover, 73.0% of patients received a Foley balloon, and 27.0% of patients did not receive a Foley balloon. There was no difference in the demographic or clinical characteristics between groups. The overall rate of clinical chorioamnionitis was 12.2%, with no difference between those with and without a Foley balloon (12.6% vs 11.1%, respectively; P=.66). Group B streptococcus status did not modify the association between Foley balloon use and clinical chorioamnionitis (relative risk, 0.93; 95% confidence interval, 0.50-1.72). This remained unchanged after adjusting for gestational age (adjusted relative risk, 0.87; 95% confidence interval, 0.45-1.67). Furthermore, other maternal and neonatal outcomes were similar between groups.

CONCLUSION

In this secondary analysis of a large randomized trial using a standardized labor protocol, there was no increased risk of infectious morbidity with Foley balloon use in patients overall and in patients with group B streptococcus. Our findings support that a Foley balloon can be safely used for cervical ripening in patients with group B streptococcus colonization.

Expediting labor induction in severe pre-eclampsia by earlier initiation of oxytocin after cervical ripening: A randomized study from India

OBJECTIVE

To observe whether induction of labor (IoL) among women with severe pre-eclampsia (PE) can be expedited by initiating oxytocin early (after 6 h) than after 12 h following cervical ripening with a combined method.

METHODS

Women with severe PE and Bishop's < 6 (n = 96) were randomized into two groups. All women received cervical ripening with a combined method (intracervical Foley's plus dinoprostone gel 0.5 mg) following which Group 1 women received oxytocin after 6 h (with Foley's in-situ) and Group 2 after 12 h (after removing Foley's) RESULTS: Majority were nulliparous (63% in group 1 and 77% in group 2) and the mean gestation was similar (35.3 ± 2.98 weeks in group 1 and 35.5 ± 3.09 in group 2). Nearly half the women had partial HELLP/ HELLP (47.9% and 54.1%; in groups 1 and 2, respectively). The induction-delivery interval (IDI) was significantly reduced in group 1 (16 h 6 min vs 22 h 6 min in group 2; p = 0.001). The cesarean section (CS) rate was 37.5% in group 1 and 31.3% in group 2 (p = 0.525), but the study was underpowered to assess this outcome. The neonatal outcome was similar, 92/96 neonates were discharged after a hospital stay of 3-52 days. There were 4 neonatal deaths (1 in group 1 and 3 in group 2) of extreme or very preterm neonates (27-30 + 6 wks) with birth weight of 735-965 gm.

CONCLUSION

Among women with severe PE undergoing IoL, initiating oxytocin 6 h after cervical ripening with a combined method reduced the IDI significantly as compared to initiating it after 12 h, with a similar CS rate and neonatal outcome.

A randomized controlled trial of sequential vs simultaneous use of Foley balloon catheter and oxytocin for induction of labor in nulliparous pregnant women

BACKGROUND

Although recent evidence suggests the simultaneous approach use of oxytocin for induction of labor in nullipara, there is limited data from low-income settings that support this.

OBJECTIVE

This study aimed to determine whether induction of labor with simultaneous use of oxytocin and a Foley balloon catheter decreases the induction of labor to delivery interval in nulliparous women, compared with sequential use of a Foley balloon catheter followed by oxytocin.

STUDY DESIGN

This was a randomized controlled trial of nulliparous women with singleton pregnancies presenting for induction of labor at >28 weeks of gestation at St. Paul's Hospital Millennium Medical College (Addis Ababa, Ethiopia). The participants were randomly assigned to either the simultaneous group (the use of oxytocin and a Foley balloon catheter for induction of labor) or the sequential group (overnight intracervical Foley balloon catheter placement followed by the use of oxytocin the next morning). The primary outcome was induction of labor to delivery interval. Comparisons between the groups were made using the Student t test or Wilcoxon rank-sum test and chi-square test on Stata (version 15; StataCorp LLC, College Station, TX). This study is registered with the Pan African Clinical Trials Registry (identifier: PACTR201709002509200).

RESULTS

From November 2019 to March 2020, a total of 140 women were randomly assigned to the simultaneous group (70 women) or the sequential group (70 women). The median oxytocin initiation to delivery intervals were 6.09 hours (range, 4.03-10.7) in the sequential group and 8.1 hours (range, 4.7-11.6) in the simultaneous group (P=.46). The mean Foley balloon catheter insertion to delivery intervals were 16.09±5.7 hours in the sequential group and 8.06±4.2 hours in the simultaneous group (P<.001). Cesarean delivery rate, composite neonatal outcomes, and chorioamnionitis were not different between the 2 groups.

CONCLUSION

In nulliparous pregnant women, induction of labor using the simultaneous approach did not shorten the oxytocin initiation to delivery interval compared with the sequential approach. Moreover, both approaches showed no difference in the rates of adverse maternal and neonatal outcomes.

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.

Longitudinal Ultrasound Evaluation of Dilapan-S During Cervical Ripening

OBJECTIVE

To assess the diameter change of hygroscopic rod dilation during 12 hours of cervical ripening.

METHODS

This was an observational, prospective study of term women undergoing labor induction with a bishop score ≤ 6. Women were allocated into two groups (soaked gauze or no gauze) stratified by parity. Using transvaginal ultrasound, maximal rod diameters were obtained in a longitudinal plane. Measurements were taken at four pre-specified time points (3, 6, 8, and 12 hours). All rods were removed at 12 hours from insertion. Patient satisfaction scores between the groups were assessed. To evaluate if measures were significantly different among the four time points, a generalized linear model was used. Independent t-tests were used to compare mean rod diameter values and pain measures between the two groups. Fisher Exact tests were used to evaluate categorical satisfaction measures.

RESULTS

Forty-four women were recruited with a total of 178 hygroscopic rods placed. Mean rod diameters (mm) were significantly different among the four time periods (3 hour: 7.9 mm [SD 0.9]; 6 hour: 9.4 mm [SD 0.9]; 8 hour: 10.0 mm [SD 0.9]; 12 hour: 10.9 mm [SD 0.8]; P-value <.001). After stratifying by the use of gauze, there was no difference in rod diameters at 3, 6, 8, and 12 hours respectively. There was no difference in patient satisfaction scores between the two groups.

CONCLUSION

The majority of hygroscopic rod dilation occurs within the first 8 hours of cervical ripening. Placement of saturated gauze does not accelerate rod dilation.

Evidence-Based Approaches to Labor Induction

Importance

The induction rate continues to increase in the United States placing pressure on the health care system with increasing cost and time spent on labor and delivery. Most labor induction regimens have evaluated uncomplicated singleton-term gestations. Unfortunately, the optimal labor regimens of medically complicated pregnancies have not been well described.

Objective

The aim of this study was to review the current available evidence regarding the various labor induction regimens and understand the evidence that exists for induction regimens in complicated pregnancies.

Evidence Acquisition

Data were acquired by a literature search on PubMed, ClinicalTrials.gov, the Cochrane Review database, the most recent American College of Obstetricians and Gynecologists practice bulletin on labor induction, and a review of the most recent edition on widely used obstetric texts for key words related to labor induction.

Results

Many heterogeneous clinical trials exist examining various labor induction regimens such as prostaglandin only, oxytocin only, or a combination of mechanical dilation with prostaglandins or oxytocin. Several Cochrane systematic reviews have been performed, which suggest a combination of prostaglandins and mechanical dilation results in an improved time to delivery when compared with single-use methods. Evaluating pregnancies complicated by maternal or fetal conditions, there exist retrospective cohorts describing significantly different labor outcomes. Although a few of these populations have planned or active clinical trials, most do not have an optimal labor induction regimen described.

Conclusions and Relevance

Most induction trials are significantly heterogeneous and limited to uncomplicated pregnancies. A combination of prostaglandins and mechanical dilation may result in improved outcomes. Complicated pregnancies have significantly different labor outcomes; however, almost none have well-described labor induction regimens.

Intracervical Foley catheter plus intravaginal misoprostol compared to intravaginal misoprostol-only for cervical ripening: A systematic review and meta-analysis

To compare the combination of intracervical Foley catheter and intravaginal misoprostol administration versus intravaginal misoprostol administration-only for cervical ripening. The Medline, EMBASE, ClinicalTrials.gov, PROSPERO, Scopus, and Cochrane Collaboration databases were searched systematically. Randomized controlled trials that included patients with a singleton viable fetus who underwent induction of labor that required cervical ripening with an unfavorable cervix (Bishop ≤ 6) were eligible for inclusion. Primary outcomes was time to delivery and rate of cesarean delivery. Thirteen trials with 2978 subjects met the inclusion criteria. There was no difference in the incidence of cesarean delivery between the two groups (RR, 0.90; 95 % CI, 0.72-1.14; I² = 69 %). The combination group resulted in comparable time to delivery (MD -2.50 h; 95 % CI 0.38, -5.38; I² = 97 %), shorter time to vaginal delivery (MD -3.49 h; 95 % CI -4.89, -2.09; I² = 81 %), lower risk of neonatal intensive care unit (NICU) admission (RR 0.72, 95 % CI 0.58-0.90, I² = 0 %), meconium-stained fluid (RR 0.48, 95 % CI 0.31-0.73, I² = 28 %), and tachysystole with fetal heart trace changes (RR 0.49, 95 % CI 0.27-0.86, I² = 43 %), compared with intravaginal misoprostol-only group. There was no statistical difference in rates of terbutaline use, endometritis or chorioamnionitis between the two groups. The combination of intravaginal misoprostol with intracervical Foley catheter for cervical ripening is not associated with shorter time to delivery. However, the combination group shows significant difference in shorter time to vaginal delivery, NICU admission, meconium-stained fluid, and tachysystole with fetal heart trace changes.

Foley catheter plus misoprostol versus misoprostol alone for labor induction

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.

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.

Novel Evidence-Based Labor Induction Algorithm Associated with Increased Vaginal Delivery within 24 Hours

OBJECTIVE

This study aimed to assess whether concordance with our proposed labor induction algorithm is associated with an increased rate of vaginal delivery within 24 hours.

STUDY DESIGN

We conducted a retrospective review of 287 induction of labors (IOLs) at a single urban, tertiary, academic medical center which took place before we created an evidence-based IOL algorithm. We then compared the IOL course to the algorithm to assess for concordance and outcomes. Patients age 18 years or over with a singleton, cephalic pregnancy of 36^6/7 to 42^0/7 weeks' gestation were included. Patients were excluded with a Bishop's score >6, contraindication to misoprostol or cervical Foley catheter, major fetal anomalies, or intrauterine fetal death. Patients with 100% concordance were compared with <100% concordant patients, and patients with ≥80% concordance were compared with <80% concordant patients. Adjusted hazard ratios (AHRs) were calculated for rate of vaginal delivery within 24 hours, our primary outcome. Competing risk's analysis was conducted for concordant versus nonconcordant groups, using vaginal delivery as the outcome of interest, with cesarean delivery (CD) as a competing event.

RESULTS

Patients with 100% concordance were more likely to have a vaginal delivery within 24 hours, n = 66 of 77 or 85.7% versus n = 120 of 210 or 57.1% (p < 0.0001), with an AHR of 2.72 (1.98, 3.75, p < 0.0001) after adjusting for delivery indication and scheduled status. Patients with 100% concordance also had shorter time from first intervention to delivery (11.9 vs. 19.4 hours). Patients with ≥80% concordance had a lower rate of CD (11/96, 11.5%) compared with those with <80% concordance (43/191 = 22.5%; p = 0.0238). There were no differences in neonatal outcomes assessed.

CONCLUSION

Our IOL algorithm may offer an opportunity to standardize care, improve the rate of vaginal delivery within 24 hours, shorten time to delivery, and reduce the CD rate for patients undergoing IOL.

KEY POINTS

· Studies on IOL have focused on individual steps. A labor induction algorithm allows for standardization.. · Algorithm concordance is associated with decreased time to delivery.. · Algorithm concordance is associated with decreased CD rate..

Effectiveness of aromatherapy in reducing duration of labour: a systematic review

Childbirth is one of the most important events in woman's life. Different methods are typically used for labour augmentation. Aromatherapy is one of the complementary methods. The present systematic review evaluated the efficacy of aromatherapy in reducing the duration of labour. A systematic search of all clinical trials studies on Cochrane, Scopus, Web of Science, PubMed, ProQuest, Google scholar, Irandoc, Science direct, Magiran and Sid was performed up to September 2021. A total of 22 articles met the inclusion criteria and 3234 women used a variety of aromatherapies. Results showed that some aromatherapies, such as lavender was almost effective in reducing length of labour. Results suggest that some aromatherapy can be an effective, inexpensive and holistic method of reducing the duration of labour but it should be used with caution.

Synthetic osmotic dilators (Dilapan-S) or dinoprostone vaginal inserts (Propess) for inpatient induction of labour: A UK cost-consequence model

OBJECTIVE

To estimate the costs of synthetic osmotic dilators (Dilapan-S) compared to dinoprostone vaginal inserts (Propess) for inpatient induction of labour (IOL).

STUDY DESIGN

A population-level, Markov model-based cost-consequence analysis was developed to compare the impact of using Dilapan-S versus Propess. The time horizon was modelled from admission to birth. The target population was women requiring inpatient IOL from 37 weeks with an unfavourable cervix in the UK. Mean population characteristics reflected those of the SOLVE (NCT03001661) trial. No patient data were included in this analysis. The care pathways and staff workload were modelled using data from the SOLVE trial and clinical experience. Cost and clinical inputs were sourced from the SOLVE trial and peer-reviewed literature. Costs were inflated to 2020 British pounds (GBP, £). Outcomes were reported as an average per woman for total costs and required staff time (minutes) from admission for IOL until birth. The model robustness was assessed using a probabilistic, multivariate sensitivity analysis of 2,000 simulations with results presented as the median (interquartile range, IQR).

RESULTS

Dilapan-S was cost neutral compared to Propess. Midwife and obstetrician times were decreased by 146 min (-11%) and 11 min (-54%), respectively. Sensitivity analysis showed that in 78% of simulations, use of Dilapan-S reduced midwife time with a median of -160 min (IQR -277 to -24 min). Costs were reduced in 54% of simulations (median -£33, IQR -£319 to £282).

CONCLUSIONS

The model indicates that adoption of Dilapan-S is likely to be cost-neutral and reduce staff workload in comparison to Propess. Results require support from real-world data and further exploration of Dilapan-S is to be encouraged.

Early vs expectant artificial rupture of membranes following Foley catheter ripening: a randomized controlled trial

BACKGROUND

Early amniotomy shortens the duration of spontaneous labor, yet there is no clear evidence on the optimal timing of amniotomy following cervical ripening. There are limited high-quality studies on the use of early amniotomy intervention following labor induction.

OBJECTIVE

This study aimed to evaluate whether amniotomy within 1 hour of Foley catheter expulsion reduces the duration of labor among individuals undergoing combined misoprostol and Foley catheter labor induction at term.

STUDY DESIGN

This was a randomized clinical trial conducted from November 2020 to May 2021 comparing amniotomy within 1 hour of Foley catheter expulsion (early artificial rupture of membranes) with expectant management. Randomization was stratified by parity. Labor management was standardized among participants. Individuals undergoing induction at ≥37 weeks with a singleton gestation and needing cervical ripening were eligible. Our primary outcome was time to delivery. Wilcoxon rank sum, Pearson chi-square, and Cox survival analyses with intent-to-treat principles were performed adjusting for age, body mass index, parity, mode of delivery, Bishop score, and the interaction between randomization group and parity. A sample size of 160 was planned to detect a 4-hour reduction in delivery time.

RESULTS

A total of 160 patients (79 early artificial rupture of membranes, 81 expectant management) were randomized. Early artificial rupture of membranes achieved a faster median time to delivery than expectant management (early artificial rupture of membranes: 11.1 hours; interquartile range, 6.25-17.1 vs expectant management: 19.8 hours; interquartile range, 13.2-26.2; P<.001). A greater percentage of individuals in the early artificial rupture of membranes group delivered within 24 hours (86% vs 70%; P=.03). There was no difference in the cesarean delivery rate between the 2 groups (22% vs 31%; P=.25). Individuals delivered 2.3 times faster following early artificial rupture of membranes (hazard ratio, 2.3; 95% confidence interval, 1.5-3.4; P<.001). There were no significant differences in maternal and neonatal outcomes.

CONCLUSION

Amniotomy within 1 hour of Foley catheter expulsion resulted in 2.3 times faster delivery than expectant management. Therefore, early artificial rupture of membranes should be considered in individuals undergoing mechanical cervical ripening at term.

Analysis of Variables that Influence the Success Rates of Induction of Labor with Misoprostol: A Retrospective Observational Study

OBJECTIVE

 Determine the predictive criteria for success in inducing labor for live fetuses using misoprostol in pregnant women. Secondarily, the objective is to determine the rates of vaginal or cesarean delivery, duration of induction, interval of administration of misoprostol, the main causes of induction of labor and indication for operative delivery.

METHODS

 Medical records of 873 pregnant women admitted for cervical maturation from January 2017 to December 2018 were reviewed in a descriptive observational study of retrospective analysis, considering the following response variables: age, parity, Bishop Index, doses of misoprostol, labor induction time. Logistic regression models were used to predict success with misoprostol in non-operative deliveries.

RESULTS

 Of the 873 patients evaluated, 72% evolved with vaginal delivery, 23% of the cases were cesarean, 5% forceps or vacuum-extractor. For non-operative delivery the predictive variables at admission were age, parity, gestational age and dilation. During hospitalization, fewer vaginal touches, amniotomy or amniorrhexis with clear fluid lead to a shorter induction time and a greater chance of non-operative delivery. False positives and false negatives of the model were always below 50% and correct answers above 65%.

CONCLUSION

 At admission, age less than 24 years, previous normal births, lower the gestational age and greater the dilation, were predictive of greater probability of non-operative delivery. During hospitalization, the less vaginal touches and occurrence of amniotomy/amniorrhexis with clear liquid indicate shorter induction time. Future studies with a prospective design and analysis of other factors are necessary to assess the replicability, generalization of these findings.

Comparison of delivery outcomes in low-dose and high-dose oxytocin regimens for induction of labor following cervical ripening with a balloon catheter: A retrospective observational cohort study

A variety of oxytocin regimens are used for labor induction and augmentation. Considering the increasing rates of labor induction, it is important to assess the most optimal oxytocin regimen without compromising maternal and fetal safety. The aim of this study was to compare delivery outcomes of low-dose and high-dose oxytocin induction protocols. This retrospective cohort study of 487 women comparing low-dose oxytocin protocol (n = 280) and high-dose oxytocin protocol (n = 207) in labor induction following cervical ripening by balloon catheter was performed in Helsinki University Hospital after implementation of a new oxytocin induction protocol. The study included two six-month cohorts from 2016 and 2019. Women with vital singleton pregnancies ≥37 gestational weeks, cephalic presentation, and intact amniotic membranes were included. The primary outcome was the rate of vaginal delivery. The secondary outcomes were the rates of maternal and neonatal infections, postpartum hemorrhage, umbilical artery blood pH-value, admission to neonatal intensive care, and induction-to-delivery interval. Statistical analyses were performed by using IBM SPSS Statistics for Windows (Armonk, NY, USA). The rate of vaginal delivery was higher [69.9% (n = 144) vs. 47.9% (n = 134); p<0.004] and the rates of maternal and neonatal infection were lower during the new high-dose oxytocin protocol [maternal infections 13.6% (n = 28) vs. 22.1% (n = 62); p = 0.02 and neonatal infection 2.9% (n = 6) vs. 14.6% (n = 41); p<0.001, respectively]. The rates of post-partum hemorrhage, umbilical artery blood pH-value <7.05 or neonatal intensive care admissions did not differ between the cohorts. The median induction-to-delivery interval was shorter in the new protocol [32.0 h (IQR 18.5–42.7) vs. 37.9 h (IQR 27.8–52.8); p<0.001]. In conclusion, implementation of the new continuous high-dose oxytocin protocol resulted in higher rate of vaginal delivery and lower rate of maternal and neonatal infections. Our experience supports the use of high-dose continuous oxytocin induction regimen with a practice of stopping oxytocin once active labor is achieved, and a 15–18-hour maximum duration for oxytocin induction in the latent phase of labor following cervical ripening with a balloon catheter.

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.

Outpatient Cervical Ripening with Balloon Catheters: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate whether outpatient cervical ripening with a balloon catheter results in a shorter amount of time in the labor and delivery unit when compared with use in the inpatient setting.

DATA SOURCES

PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov were searched from their inception until December 2020. No restrictions for language or geographic location were applied.

METHODS OF STUDY SELECTION

Using a predefined protocol and search strategy, 1,152 titles were identified and screened. Randomized controlled trials that compared outpatient and inpatient cervical ripening with balloon catheters were included.

TABULATION, INTEGRATION, AND RESULTS

Data extraction and risk of bias assessments were performed by two reviewers. Meta-analysis was performed to produce mean difference for continuous data and risk ratio (RR) for dichotomous data, both with a 95% CI. The primary outcome was the amount of time from admission to the labor ward until delivery. Additional secondary maternal and neonatal outcomes were evaluated. Eight trials (740 patients) were included; six studies (571 patients) reported on our primary outcome. Compared with the inpatient group, outpatient balloon cervical ripening was associated with significantly less time in the labor and delivery unit (outpatient 16.3±9.7 hours vs inpatient 23.8±14.0 hours; mean difference -7.24 hours, 95% CI -11.03 to -3.34). There were no differences in total induction time or total hospital admission. The outpatient group was significantly less likely than the inpatient group to undergo cesarean delivery (21% vs 27%), RR 0.76 (95% CI 0.59-0.98). There were no differences in other maternal or neonatal outcomes. There were no deliveries outside of the hospital and no stillbirths.

CONCLUSION

Outpatient balloon cervical ripening in low-risk patients is associated with a decreased amount of time from admission to labor and delivery until delivery. Outpatient balloon cervical ripening is a safe alternative for low-risk patients and has the potential for significant benefits to patients, and labor and delivery units.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019140503.

Foley catheter and controlled release dinoprostone versus foley catheter labor induction in nulliparas: a randomized trial

PURPOSE

To evaluate Foley catheter and controlled release dinoprostone insert compared to foley catheter alone on induction to delivery interval and maternal satisfaction.

METHODS

A randomized trial was conducted in a university hospital in Malaysia from December 2018 to May 2019. Term nulliparas with unfavorable cervix (Bishop score ≤ 5) scheduled for labor induction were randomized to Foley catheter and controlled release dinoprostone insert simultaneously or Foley catheter alone. Primary outcomes were induction to delivery interval (hours) and maternal satisfaction on birth experience (assessed by 11-point Visual Numerical Rating Scale VNRS 0-10, higher score more satisfied).

RESULTS

Induction to vaginal delivery intervals was mean ± standard deviation 22.5 ± 10.4 vs. 35.1 ± 14.9 h, P =  < 0.001 but maternal satisfaction on birth experience was not significantly different median[interquartile range] VNRS 8[7-9] vs. 8[7-9], P = 0.12 for Foley catheter-controlled-release dinoprostone and Foley catheter alone arms, respectively. Cesarean delivery rates were 35/102(34.3%) vs. 50/101(49.5%), P = 0.02 RR 0.7 95% CI 0.5-0.9 NNTb 6.3 95% CI 3.5-39.4, pain score at 6 h after catheter insertion 5[2-8] vs. 1[1-3], P < 0.001, Bishop score at trial devices removal 9[9-10] vs. 8[7-9], P = 0.001, requirement for oxytocin induction or augmentation 39/102(38.2%) vs. 76/101(75.2%) NNTb 3 95% CI 2.0-4.1, P < 0.001 and amniotomy rates 73/99(73.7%) vs. 81/95(85.3%), P = 0.052 RR 0.9 85% CI 0.8-1.0 in Foley catheter-controlled-release dinoprostone and Foley catheter alone arms respectively.

CONCLUSION

In nulliparas with unripe cervixes at term, combined Foley catheter and controlled release dinoprostone vaginal insert compared to Foley catheter alone reduces the induction to vaginal delivery interval and cesarean delivery rate but satisfaction was not significantly increased.

CLINICAL TRIAL REGISTRATION

ISRCTN2282883, 03/12/2018, "prospectively registered" ( https://doi.org/10.1186/ISRCTN12282883 ).

American College of Nurse-Midwives Clinical Bulletin Number 18: Induction of Labor

Induction of labor is an increasingly common component of intrapartum care in the United States. This rise is fueled by a nationwide escalation in both medically indicated and elective inductions at or beyond term, supported by recent research showing some benefits of induction over expectant management. However, induction of labor medicalizes the birth experience and may lead to a complex cascade of interventions. The purpose of this Clinical Bulletin is twofold: (1) to guide clinicians on the use of person-centered decision-making when discussing induction of labor and (2) to review evidence-based practice recommendations for intrapartum midwifery care during labor induction.

Moving preinduction cervical ripening to a lower acuity inpatient setting using the synthetic hygroscopic cervical dilator: a cost-consequence analysis for the United States

BACKGROUND

Leveraging the safety profile of the synthetic hygroscopic cervical dilator (SHCD), one potential way to reduce the burden-of-care provision in the labor-and-delivery unit without compromising safety is to introduce a low-acuity care room (ripening room) for patients undergoing cervical ripening as a part of labor induction at term.

METHODS

Implementing a ripening room using SHCDs was compared to scenarios using prostaglandins including a dinoprostone insert (PGE2 insert) or gel (PGE2 gel) and misoprostol given orally (oral PGE1) or vaginally (vaginal PGE1). A theoretical, cost-consequence model was developed to assess costs, staff time, and selected clinical outcomes related to cervical ripening. The model assessed a hypothetical cohort where patients remained in hospital from admission for induction of labor (IOL) to delivery, taking the US labor-and-delivery unit perspective. Model inputs were taken from structured searches of PubMed and ClinicalTrials.gov, published US guidance, and clinical practice. Results are presented as mean (95% credible interval [CrI]).

RESULTS

The ripening room using SHCDs cost US$3,210 and required 10.22 hours (h) of nurse time on average per patient. The cost difference to prostaglandins ranged from -$894 (-$2,269 to $398) for PGE2 gel to +$460 (-$1,467 to $1,539) for vaginal PGE1. Mean nurse time was shorter than all prostaglandins, with time savings ranging from -7.05 (-24.55 to 5.73) h for PGE2 insert to -0.97 (-14.69 to 9.59) h for vaginal PGE1. When outcomes of the probabilistic sensitivity analysis were ranked from 1 (best) to 5 (worst), the ripening room using SHCDs ranked 1.94 for costs and 1.97 for nurse time. In a nulliparous population, results improved for the ripening room using SHCDs relative to all prostaglandins.

CONCLUSION

In this theoretical study, implementing a ripening room using SHCDs resulted in the lowest time burden and the second lowest costs. The cheapest option for preinduction cervical ripening was vaginal misoprostol.

Outpatient Cervical Ripening With Misoprostol in Low-Risk Pregnancies

Objective To determine if outpatient cervical ripening with daily misoprostol can reduce admission to delivery time in women with low-risk pregnancies at 39 or more weeks of gestation. Study design This is a retrospective cohort study of a convenience sample of low-risk pregnancies that underwent elective outpatient cervical ripening compared to matched controls for parity (nulliparous vs. parous) and gestational age. Time from admission to delivery, induction agents, presence of tachysystole, mode of delivery, length of hospitalization, neonatal intensive care unit (NICU) admission, and low Apgar scores were compared. Results Fifty-six patients who underwent outpatient cervical ripening with daily dosing of misoprostol were compared to 56 patients matched for parity and gestational weeks who underwent inpatient cervical ripening/induction of labor with misoprostol. We found the time from admission to delivery in the outpatient cervical ripening cohort was significantly lesser than the inpatient cohort (17.5 ± 11.5 hours outpatient vs. 26.6 ± 15.6 hours inpatient, P=0.001). More patients (N=18, 32%) were able to deliver within 12 hours of admission in the outpatient induction group compared to the inpatient group (N=8, 11%, P=0.010). There were no differences in frequency of cesarean delivery, uterine tachysystole with or without fetal heart rate changes, NICU admission, low Apgar scores, or low umbilical artery pH values between the two groups. Conclusion Outpatient cervical ripening with misoprostol may be a feasible alternative to inpatient cervical ripening in low-risk pregnancies, may help improve patient experience, and reduce the operational burden that elective induction confers upon labor and delivery units.

Outpatient Foley catheter induction protocol provides clinical and cost benefits

BACKGROUND

Obstetric induction procedures are expensive, and little is known of the specific difference in cost between inpatient and outpatient protocols for these procedures.

OBJECTIVE

The objective of this study was to examine the difference in health care costs, maternal and neonatal morbidity, and cesarean birth rates for inpatient versus outpatient Foley induction protocols.

MATERIAL AND METHODS

We conducted a retrospective study using deliveries from 2013 to 2015 that received an outpatient or inpatient Foley catheter induction. Inductions were matched by race, parity, and maternal age. We used univariate and multivariate logistic regression to test the association between type of induction, length of stay, and cost. Maternal and neonatal factors and cesarean rates were also considered.

RESULTS

A total of 163 outpatient Foley inductions were matched 1:1 to inpatient inductions. Outpatient inductions were more likely to have a shorter length of hospitalization from admission to discharge (a 7.17-hour difference, 95% CI, 71.00, 77.59) and lower costs of hospitalization ($408 per patient, 95% CI, 4305, 4714). In the univariate analysis, there was no difference in rate of cesarean birth (OR 0.95, 95% CI, 0.61, 1.48). However, in the multivariate analysis, there was a decreased rate of cesarean for outpatient inductions (OR 0.5, 95% CI, 0.26, 0.97).

CONCLUSIONS

Outpatient Foley catheter induction appears to be a safe, cost-effective method for induction of labor. Generating protocols allowing patients to receive quality care in an outpatient setting is increasingly important in current health care environments.

Risk of Cesarean Delivery for Women with Obesity Using a Standardized Labor Induction Protocol

OBJECTIVE

We aimed to determine the risk of cesarean among women with obesity undergoing labor induction within a prospective trial that utilized a standardized labor protocol.

STUDY DESIGN

This was a secondary analysis of a randomized trial of induction methods. Term (≥37 weeks) women with intact membranes undergoing induction with an unfavorable cervix (Bishop's score ≤6 and dilation ≤2 cm) were included. The trial utilized a labor protocol that standardized induction and active labor management, with recommendations for interventions at particular time points. Only women with a recorded body mass index (BMI) at prenatal care start were included in this analysis. The primary outcome was cesarean delivery compared between obese (≥30 kg/m²) and nonobese (<30 kg/m²) women. Indication for cesarean was also evaluated.

RESULTS

A total of 465 women were included: 207 (44.5%) obese and 258 (55.5%) nonobese. Women with obesity had a higher risk of cesarean compared with women without obesity (33.3 vs. 23.3%, p = 0.02), even when adjusting for parity, weight change over pregnancy, and indication for induction (adjusted relative risk [aRR] = 1.79, 95% confidence interval [CI]: [1.34-2.39]). Compared with women without obesity, women with obesity had a higher risk of failed induction (47.8 vs. 26.7%, p = 0.01) without a difference in arrest of active phase (p = 0.39), arrest of descent (p = 0.95) or fetal indication (p = 0.32), despite adherence to a standardized labor protocol.

CONCLUSION

Compared with women without obesity, women with obesity undergoing an induction are at increased risk of cesarean, in particular a failed induction, even within the context of standardized induction management. As standardized practices limit provider variation in labor management, this study may support physiologic differences in labor processes secondary to obesity.

KEY POINTS

· Even with a standardized induction protocol, women with obesity are at higher risk of cesarean.. · In particular, women with obesity are at increased risk of cesarean for failed induction.. · These findings support a possible biologic relationship between obesity and failed induction..

Labor and Delivery Outcomes with the Sequential Use of Misoprostol Followed by Cervical Foley Catheter

OBJECTIVE

Studies demonstrate shorter time to delivery with concurrent use of misoprostol and cervical Foley catheter. However, concurrent placement may not be feasible. If misoprostol is used to start an induction, little is known regarding the benefit of sequentially using Foley catheter. We examine obstetrical outcomes in women with Foley catheter placed after misoprostol compared with those only requiring misoprostol.

STUDY DESIGN

Retrospective cohort study of singleton pregnancies, intact membranes, and an unfavorable cervix (Bishop score of ≤6 and dilation ≤2 cm) undergoing term induction May 2013 to June 2015. We compared obstetrical outcomes between women receiving misoprostol alone versus those that had a Foley catheter placed after misoprostol. Outcomes are mode of delivery, time to delivery, chorioamnionitis, admission to neonatal intensive care unit, and maternal morbidity. Chi-square and Fisher's exact tests were used for categorical variables, Mann-Whitney U-tests compared continuous variables.

RESULTS

Among 364 women, 281 began induction with misoprostol alone. A total of 135 (48%) subsequently had a Foley catheter placed. Characteristics were similar between the groups, although nulliparity and cervical dilation <1 cm at start of induction were more likely to have subsequent Foley catheter. Women with Foley catheter placement after misoprostol had a longer median time to delivery (15 vs. 11 hours, p < 0.001), twofold higher rate of cesarean (42 vs. 26%, odds ratio: 2.1, 95% confidence interval: 1.26-3.44, p = 0.004), and increased risk of neonatal intensive care unit (NICU) admission (21 vs. 11%, p = 0.024). There was a nonsignificant increased risk of chorioamnionitis (12 vs. 7%, p = 0.1) and maternal morbidity (15 vs. 8%, p = 0.08) in the misoprostol followed by Foley catheter group.

CONCLUSION

In women receiving misoprostol for induction, nulliparas and those with dilation <1 cm are more likely to have subsequent Foley catheter placement. Sequential use of cervical Foley catheter after misoprostol is associated with longer labor, higher cesarean rate, and increased NICU admission. Requirement of Foley catheter after misoprostol confers higher risk and may guide counseling.

KEY POINTS

· Little is known regarding efficacy of misoprostol followed by cervical Foley catheter.. · Nulliparas and dilation <1 cm increases need for Foley after misoprostol.. · Complications were more common in women requiring Foley after misoprostol..

Favorable Simplified Bishop Score after cervical ripening associated with decreased cesarean birth rate

BACKGROUND

A favorable Simplified Bishop Score (>5) before the induction of labor is associated with successful vaginal birth. Patients with an unfavorable Simplified Bishop Score (≤5) undergo cervical ripening before the administration of oxytocin. However, data are limited regarding the utility of the Simplified Bishop Score after cervical ripening.

OBJECTIVE

The objective of this study was to determine if the Simplified Bishop Score before oxytocin induction but after cervical ripening is associated with cesarean delivery.

STUDY DESIGN

We conducted a retrospective cohort study on patients undergoing induction of labor from the Consortium on Safe Labor. The patients with a singleton term pregnancy who initially underwent cervical ripening were included. Those with a history of cesarean delivery were excluded. The outcomes of patients with a favorable Simplified Bishop Score after cervical ripening were compared with those with an unfavorable Simplified Bishop Score. The primary outcome was the mode of birth. A log-binomial regression was performed to calculate the relative risk and control for confounders such as admission Simplified Bishop Score and parity.

RESULTS

A total of 5807 patients met the criteria to be included in the study. 4235 (73%) patients had a favorable cervix, and 1572 (27%) patients had an unfavorable cervix after cervical ripening. The favorable group had a decreased rate of cesarean delivery than the unfavorable group (risk ratio, 0.35; 95% confidence interval, 0.30-0.40). Both the groups had low rates of maternal chorioamnionitis, though the patients with an unfavorable cervix were at a higher risk. There was no significant difference in the rates of postpartum hemorrhage or neonatal intensive care unit admission. Lower rates of cesarean delivery among the favorable group persisted when stratifying by parity (nulliparous: risk ratio, 0.37; 95% confidence interval, 0.31-0.43; multiparous: risk ratio, 0.22; 95% confidence interval, 0.14-0.36). After controlling for maternal age, prepregnancy body mass index, parity, gestational age, and Simplified Bishop Score at admission, a favorable cervix remained significantly associated with fewer cesarean births (risk ratio, 0.55; 95% confidence interval, 0.46-0.66).

CONCLUSION

In women undergoing labor induction, a favorable Simplified Bishop Score after cervical ripening and before the start of oxytocin is associated with a decreased rate of cesarean delivery, even after adjusting for parity and Simplified Bishop Score at admission. Moreover, the Simplified Bishop Score assigned after cervical ripening could be used to inform the timing of oxytocin initiation. However, further research is necessary to determine the ideal endpoint of cervical ripening.

Misoprostol for labour induction

Oral and vaginal misoprostol are effective induction methods, but there is a delicate balance between a quicker labour and avoiding side effects. In randomised comparisons with balloon catheters, oral misoprostol resulted in more vaginal births in the first 24 h as well as fewer caesarean sections without an increase in hyperstimulation events. Vaginal misoprostol was most effective when used concurrently with a balloon catheter. In comparison with dinoprostone, oral misoprostol had lower rates of caesarean section and uterine hyperstimulation with foetal heart rate changes, but fewer babies were born vaginally within 24 h. In contrast, vaginal misoprostol resulted in more vaginal births within 24 h, with no significant differences in caesarean section rates. There were no differences in perinatal adverse events with either route. When oral and vaginal misoprostol were compared, vaginal misoprostol resulted in more vaginal births in the first 24 h, but with more maternal and neonatal complications.

Evaluating the impact of a standardized induction protocol to reduce adverse perinatal outcomes: a prospective cohort study

OBJECTIVE

Our objective was to evaluate the impact of a standardized induction protocol on reducing maternal and neonatal morbidity in women undergoing an induction with an unfavorable cervix.

STUDY DESIGN

We performed a prospective cohort study of women undergoing an induction from May 2013 to June 2015. Women who were ≥18 years, ≥37 weeks with intact membranes and an unfavorable cervix (Bishop score of ≤6 and cervical dilation ≤2 cm) with no prior cesarean were included. We compared the following outcomes between women managed with the labor protocol versus women in an observation group, managed at the discretion of the provider: Labor length, cesarean delivery, maternal and neonatal morbidity, and neonatal intensive care unit admission for >48 hours. Multivariable models incorporated confounders specific to each outcome.

RESULTS

855 women were included (491: labor protocol group; 364: observational group). Women in the labor protocol group had a shorter time to delivery (15.7 hours vs. 18.0 hours, p < .001), a decrease in maternal morbidity (7.3% vs. 11.5%, p = .04), lower rates of NICU admission >48 hours (3.5% vs 8%, p = .005), and a lower neonatal morbidity (3.0% vs. 7.7%, p = .003) compared to women in the observational group. There was no difference in rate of cesarean between the labor protocol and observational groups (27.7% vs. 32.7%, p = .13). When adjusting for confounders, women in the labor protocol group had a 60% reduction in NICU admission >48 hours (RR: 0.41, 95% CI: 0.22-0.76) and a 70% reduction in neonatal morbidity (RR: 0.31, 95% CI: 0.13-0.70). Time to delivery and maternal morbidity were not significantly different in adjusted models.

CONCLUSION

Utilization of a standardized induction protocol was associated with a significant reduction in neonatal morbidity without increasing the risk of cesarean or maternal morbidity.

Simultaneous use of high-volume Foley catheter (60 ml) and misoprostol for labor induction in nulliparous women: A randomized controlled trial

OBJECTIVE

To examine the simultaneous effect of high-volume Foley catheter (HVFC) (60 ml) and vaginal misoprostol on labor induction in nulliparous women.

METHODS

A randomized, double-blind, controlled trial was conducted among nulliparous post-date (>40 weeks) pregnant women between June and December 2019. At enrollment 100 women were randomized into each group (either HVFC and vaginal misoprostol or low-volume Foley catheter [LVFC] [30 ml] and vaginal misoprostol), for labor induction. Demographic and clinical data were collected at enrollment and delivery.

RESULTS

Women in the HVFC group had statistically significantly shorter induction to delivery interval (median 860 min, interquartile range [IQR] 840-940 min vs. 1160 min, IQR 1080-1320 min, P < 0.001) and duration of labor (median 615 min, IQR 600-680 min vs. 750, IQR 692.5-800 min, P < 0.001). Mode of vaginal delivery (n = 94 vs. n = 78, P = 0.002), number of doses of misoprostol required (median 2, IQR 1-2 vs. 2, IQR 1-3), and need of oxytocin augmentation (n = 22 vs. n = 39, P = 0.014 and P < 0.001), was significantly better in the HVFC group. However, there was no significant difference with respect to other maternal or neonatal outcomes.

CONCLUSION

Simultaneous use of HVFC and vaginal misoprostol for labor induction significantly shortens the induction to delivery interval and duration of labor in nulliparous women.

TRIAL REGISTRATION

Clinical Trial Registry of India CTRI/2019/05/019394 (http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=31554&EncHid=&userName=Foley%20catheter).

Trends, gaps, and future directions of research in cervical remodeling during pregnancy: a bibliometric analysis

PURPOSE

The cervix undergoes a dynamic remodeling process throughout pregnancy. Appropriate timing of cervical remodeling is essential in maintaining the fetus inside the uterus and ensuring cervical dilatation for safe delivery of the fetus at term. This study aims to determine the characteristics and trends of published articles in the field of cervical remodeling during pregnancy through a bibliometric analysis.

MATERIALS AND METHODS

A systematic review of the literature on cervical remodeling during pregnancy was performed on using the Scopus database from inception to 2020. The following information was obtained for each article: authors, year of publication, title, journal, institution, country, title, keywords, citation frequency, and relative citation ratio. The visualization of collaboration networks of countries and keywords related to cervical remodeling during pregnancy was conducted using VOSviewer software.

RESULTS

A total of 1979 bibliographic records were obtained from Scopus database. The number of publications increased in the 1980s and peaked in 2010. A total of 80 countries produced research in cervical remodeling during pregnancy. The USA contributed the greatest number of publications (n= 541), total citations (n= 11,971), and number of international collaborations (n= 28 countries). The American Journal of Obstetrics and Gynecology, Obstetrics and Gynecology, and BJOG: An International Journal of Obstetrics and Gynaecology are the top three contributors in this field in terms of number of publications and total citations. The Karolinska Institutet produced the greatest number of publications while UT Southwestern Medical Center was the most cited institution in this field. The topics of the top cited articles were studies regarding the role of collagen degradation in cervical remodeling during pregnancy; dynamics, anatomy, and physiology of cervical remodeling; and the use of misoprostol for cervical ripening and labor induction.

CONCLUSIONS

Our bibliometric analysis shows the trends and development, scientific impact, and collaboration in the field of cervical remodeling research. These results show the important discoveries in the past and provided new avenues for scientific and clinical investigations in the field.

Outpatient vs inpatient Foley catheter induction of labor in multiparas with unripe cervixes: A randomized trial

INTRODUCTION

Multiparous labor inductions are typically successful, and the process can be rapid, starting from a ripened cervix with a predictable response to amniotomy and oxytocin infusion. Outpatient Foley catheter labor induction in multiparas with unripe cervixes is a feasible option as the mechanical process of ripening is usually without significant uterine contractions and well tolerated. Labor contractions can be initiated by amniotomy and titrated oxytocin infusion in the hospital for well-timed births during working hours as night birth are associated with adverse events. We sought to evaluate outpatient compared with inpatient Foley catheter induction of labor in multiparas for births during working hours and maternal satisfaction.

MATERIAL AND METHODS

A randomized trial was conducted in the University of Malaya Medical Center. A total of 163 term multiparas (no dropouts) with unripe cervixes (Bishop score ≤5) scheduled for labor induction were randomized to outpatient or inpatient Foley catheter. Primary outcomes were delivery during "working hours" 08:00-18:00 h and maternal satisfaction on allocated care (assessed by 11-point visual numerical rating score 0-10, with higher score indicating more satisfied).

CLINICAL TRIAL REGISTRATION

ISRCTN13534944.

RESULTS

Comparing outpatient and inpatient arms, delivery during working hours were 54/82 (65.9%) vs. 48/81 (59.3%) (relative risk 1.1, 95% CI 0.9-1.4, p = 0.421) and median maternal satisfaction visual numerical rating score was 9 (interquartile range 9-9) vs. 9 (interquartile range 8-9, p = 0.134), repectively. Duration of hospital stay and membrane rupture to delivery interval were significantly shorter in the outpatient arm: 35.8 ± 20.2 vs. 45.2 ± 16.2 h (p = 0.001) and 4.1 ± 2.9 vs. 5.3 ± 3.6 h (p = 0.020), respectively. Other maternal and neonatal secondary outcomes were not significantly different.

CONCLUSIONS

The trial failed to demonstrate the anticipated increase in births during working hours with outpatient compared with inpatient induction of labor with Foley catheter in parous women with an unripe cervix. Hospital stay and membrane rupture to delivery interval were significantly shortened in the outpatient group. The rate of maternal satisfaction was high in both groups and no significant differences were found.

Low-dose oxytocin as an adjunct to Foley catheter for cervical ripening in nulliparous women at MTRH, Eldoret, Kenya: A randomized controlled trial

OBJECTIVE

To investigate whether the addition of oxytocin to cervical ripening with a Foley catheter (FC) among nulliparous women shortens the time to delivery.

METHODS

In this double-blinded randomized trial conducted at Moi Teaching and Referral Hospital, 220 women were randomly assigned to FC plus low-dose oxytocin as treatment or FC plus placebo as controls in a 1:1 ratio. A modified intention-to-treat analysis was performed using SPSS v24. The protocol was approved by the institutional ethics committee and registered at www.ctr.pharmacyboardkenya.org; ECCT/19/08/02.

RESULTS

Baseline characteristics were similar. Time to delivery was shorter by 3 h in the treatment group compared with the controls (25.4 versus 28.4 h, P = 0.002). The treatment group had a 22% increased likelihood of delivery within 24 h compared with the controls (53.3% versus 43.1%, relative risk [RR] 1.22, 95% confidence interval [CI] 0.938-1.579, P = 0.135). The controls were however twice more likely to deliver by cesarean section than the treatment group (39% versus 21%, RR 2.32, 95% CI 1.16-2.73, P = 0.006). There were no significant differences in neonatal or other maternal outcomes.

CONCLUSION

FC with adjunctive oxytocin for cervical ripening in nulliparous women results in a shorter time to delivery and reduced cesarean deliveries when compared with FC alone.

Maternal and Neonatal Outcomes in Nulliparous Participants Undergoing Labor Induction by Cervical Ripening Method

OBJECTIVE

 This study aimed to evaluate maternal and neonatal outcomes by method of cervical ripening for labor induction among low-risk nulliparous individuals.

STUDY DESIGN

 This is a secondary analysis of a multicenter randomized trial of labor induction at 39 weeks versus expectant management in low-risk nulliparous participants. Participants undergoing cervical ripening for labor induction in either group were included. Participants were excluded for preripening membrane rupture, abruption, chorioamnionitis, fetal demise, or cervical dilation ≥3.5 cm. Cervical ripening was defined by the initial method used: prostaglandin only (PGE; referent), Foley with concurrent prostaglandin (Foley-PGE), Foley only (Foley), and Foley with concurrent oxytocin (Foley-oxytocin). Coprimary outcomes were adverse maternal and neonatal composites. Secondary outcomes included cesarean delivery and length of labor and delivery (L&D) stay. Multivariable analysis was used to adjust for patient characteristics.

RESULTS

 Of 6,106 participants included in the trial, 2,376 (38.9%) met criteria for this analysis. Of these, 1,247 (52.4%) had cervical ripening with PGE, 290 (12.2%) had Foley-PGE, 385 (16.2%) had Foley, and 454 (19.1%) had Foley-oxytocin. The maternal composite outcome was similar among participants who received Foley-PGE (24.1%, adjusted relative risk [aRR] = 1.21, 95% confidence interval [CI]: 0.96-1.52), Foley (21.3%, aRR = 1.16, 95% CI: 0.92-1.45), or Foley-oxytocin (19.4%, aRR = 1.04, 95% CI: 0.83-1.29), compared with PGE (19.7%). The neonatal composite outcome was less frequent in participants who received the Foley-PGE (2.4%, aRR = 0.35, 95% CI: 0.16-0.75) or Foley (3.6%, aRR = 0.51, 95% CI: 0.29-0.89) but did not reach statistical significance for participants who received Foley-oxytocin (4.6%, aRR = 0.63, 95% CI: 0.40-1.01) compared with PGE only (6.8%). Participants who received Foley-PGE or Foley-oxytocin had a shorter L&D stay (adjusted mean difference = -1.97 hours, 95% CI: -3.45 to -0.49 and -5.92 hours, 95% CI: -7.07 to -4.77, respectively), compared with PGE.

CONCLUSION

 In term low-risk nulliparous participants, Foley alone or concurrent with PGE is associated with a lower risk of adverse neonatal outcomes than with PGE alone. Length of L&D stay was the shortest with concurrent Foley-oxytocin.

KEY POINTS

· Adverse maternal outcomes are similar among different methods of cervical ripening in low-risk women.. · Adverse neonatal outcomes are less frequent with use of Foley alone or in combination with PGE.. · The use of Foley alone, or in combination with other agents, appears to be beneficial..