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COZZI-GLASER GD, BLANCHARD CT, STANFORD JN, OBEN AG, JAUK VC, SZYCHOWSKI JM, SUBRAMANIAM A, BATTARBEE AN, CASEY BM, Tita AT, Sinkey RG. Outcomes in low-risk patients before and after an institutional policy offering 39-week elective induction of labor. J Matern Fetal Neonatal Med 2024; 37:2295223. [PMID: 38124289 PMCID: PMC10958525 DOI: 10.1080/14767058.2023.2295223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Elective induction of labor versus expectant management at 39 weeks gestation in low-risk nulliparous patients was shown in the ARRIVE randomized trial of over 6000 patients to decrease risks of cesarean delivery without significant change in the composite perinatal outcome. We aimed to pragmatically analyze the effect of offering elective induction of labor (eIOL) to all low-risk patients. METHODS Retrospective cohort study of low-risk nulliparous and multiparous patients delivering live, non-anomalous singletons at a single center at greater than or equal to 39 0/7 weeks gestational age. Those with prior or planned cesarean delivery, ruptured membranes, medical comorbidities, or contraindications to vaginal delivery were excluded. Patients were categorized as before (pre-eIOL; 1/2012-3/2014) or after (post-eIOL; 3/2019-12/2021) an institution-wide policy offering eIOL at 39 0/7 weeks. Births occurring April 2014 to December 2018 were allocated to a separate cohort (during-eIOL) given increased exposure to eIOL as our center recruited participants for the ARRIVE trial. The primary outcome was cesarean birth. Secondary outcomes included select maternal (e.g. chorioamnionitis, operative delivery, postpartum hemorrhage) and neonatal morbidities (e.g. birthweight, small- and large-for gestational age, hypoglycemia). Characteristics and outcomes were compared between the pre and during-eIOL, and pre and post-eIOL groups; adjusted OR (95% CI) were calculated using multivariable regression. Subgroup analysis by parity was planned. RESULTS Of 10,758 patients analyzed, 2521 (23.4%) were pre-eIOL, 5410 (50.3%) during-eIOL, and 2827 (26.3%) post-eIOL. Groups differed with respect to labor type, age, race/ethnicity, marital and payor status, and gestational age at care entry. Post-eIOL was associated with lower odds of cesarean compared to pre-eIOL (aOR 0.83 [95% CI 0.72-0.96]), which was even lower among those specifically undergoing labor induction (aOR 0.58 [0.48-0.70]. During-eIOL was also associated with lower odds of cesarean compared to pre-eIOL (aOR 0.79 [0.69-0.90]). Both during and post-eIOL groups were associated with higher odds of chorioamnionitis, operative delivery, and hemorrhage compared to pre-eIOL. However, only among post-eIOL were there fewer neonates weighing ≥4000 g, large-for-gestational age infants, and neonatal hypoglycemia compared to pre-IOL. CONCLUSION An institutional policy offering eIOL at 39 0/7 to low-risk patients was associated with a lower cesarean birth rate, lower birthweights and lower neonatal hypoglycemia, and an increased risk of chorioamnionitis and hemorrhage.
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Affiliation(s)
- Gabriella D COZZI-GLASER
- Center for Women’s Reproductive Health, University of Alabama at Birmingham
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | | | - Jenna N STANFORD
- Center for Women’s Reproductive Health, University of Alabama at Birmingham
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Ayamo G OBEN
- Center for Women’s Reproductive Health, University of Alabama at Birmingham
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Victoria C JAUK
- Center for Women’s Reproductive Health, University of Alabama at Birmingham
| | - Jeff M SZYCHOWSKI
- Center for Women’s Reproductive Health, University of Alabama at Birmingham
- Department of Biostatistics, University of Alabama at Birmingham
| | - Akila SUBRAMANIAM
- Center for Women’s Reproductive Health, University of Alabama at Birmingham
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Ashley N BATTARBEE
- Center for Women’s Reproductive Health, University of Alabama at Birmingham
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Brian M CASEY
- Center for Women’s Reproductive Health, University of Alabama at Birmingham
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Alan T Tita
- Center for Women’s Reproductive Health, University of Alabama at Birmingham
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Rachel G Sinkey
- Center for Women’s Reproductive Health, University of Alabama at Birmingham
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham
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Watters A, Ekpe E, Okafor A, Donelan E. Patient Perspectives on Outpatient versus Inpatient Cervical Ripening for Induction of Labor. Am J Perinatol 2024; 41:2119-2124. [PMID: 38569508 DOI: 10.1055/a-2298-5166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE Our objective was to compare patient perceived control and experience with outpatient versus inpatient cervical ripening. STUDY DESIGN This is a retrospective mixed-methods analysis of a quality improvement initiative focused on the impact to patients of incorporating outpatient cervical ripening into routine practice. Postpartum inpatients who had elected for outpatient cervical ripening (outpatients) and those who met criteria for outpatient cervical ripening but opted for an inpatient setting (inpatients) were invited to participate in the study. Patients completed the Perceived Control in Childbirth Scale, and scores were compared between outpatient and inpatient groups using Mann-Whitney U test. In addition, semistructured questions elicited feedback prior to hospital discharge, and these qualitative data were analyzed using iterative thematic analysis. RESULTS The study population consisted of 36 outpatients and 38 inpatients. The median score on the Perceived Control in Childbirth Scale was 69 for outpatients and 67 for inpatients (p-value = 0.49), out of a maximum score of 72 (representing the highest level of perceived control). Both groups reported similarly high levels of perceived control, regardless of cervical ripening setting. In the qualitative analysis, pain was the most common theme in both groups. Inpatients reported more distress despite access to stronger pain medications. Outpatients utilized a variety of distraction techniques and expressed gratitude for their setting more than inpatients. CONCLUSION Outpatient cervical ripening can be a patient-centered solution to obstetric throughput challenges arising from increased numbers of inductions. Those who underwent outpatient cervical ripening had similar perceived control to those who underwent inpatient cervical ripening, suggesting that individual patient preferences are most important in determining the optimal setting for care. The patients' reported experiences identified focus areas for process improvement efforts and future research, including improving patient education regarding expectations and innovating new pain management strategies for cervical ripening. KEY POINTS · Patient experiences must inform patient-centered care.. · Perceived control with cervical ripening was high.. · Pain with cervical ripening was the most cited theme..
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Affiliation(s)
- Amber Watters
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Etoroabasi Ekpe
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Illinois
| | - Annette Okafor
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- University of Illinois College of Medicine, Chicago, Illinois
| | - Emily Donelan
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Obstetrics and Gynecology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
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Graf EM, McKinney JA, Dye AB, Lin L, Sanchez-Ramos L. Exploring the Limits of Artificial Intelligence for Referencing Scientific Articles. Am J Perinatol 2024; 41:2072-2081. [PMID: 38653452 DOI: 10.1055/s-0044-1786033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE To evaluate the reliability of three artificial intelligence (AI) chatbots (ChatGPT, Google Bard, and Chatsonic) in generating accurate references from existing obstetric literature. STUDY DESIGN Between mid-March and late April 2023, ChatGPT, Google Bard, and Chatsonic were prompted to provide references for specific obstetrical randomized controlled trials (RCTs) published in 2020. RCTs were considered for inclusion if they were mentioned in a previous article that primarily evaluated RCTs published by the top medical and obstetrics and gynecology journals with the highest impact factors in 2020 as well as RCTs published in a new journal focused on publishing obstetric RCTs. The selection of the three AI models was based on their popularity, performance in natural language processing, and public availability. Data collection involved prompting the AI chatbots to provide references according to a standardized protocol. The primary evaluation metric was the accuracy of each AI model in correctly citing references, including authors, publication title, journal name, and digital object identifier (DOI). Statistical analysis was performed using a permutation test to compare the performance of the AI models. RESULTS Among the 44 RCTs analyzed, Google Bard demonstrated the highest accuracy, correctly citing 13.6% of the requested RCTs, whereas ChatGPT and Chatsonic exhibited lower accuracy rates of 2.4 and 0%, respectively. Google Bard often substantially outperformed Chatsonic and ChatGPT in correctly citing the studied reference components. The majority of references from all AI models studied were noted to provide DOIs for unrelated studies or DOIs that do not exist. CONCLUSION To ensure the reliability of scientific information being disseminated, authors must exercise caution when utilizing AI for scientific writing and literature search. However, despite their limitations, collaborative partnerships between AI systems and researchers have the potential to drive synergistic advancements, leading to improved patient care and outcomes. KEY POINTS · AI chatbots often cite scientific articles incorrectly.. · AI chatbots can create false references.. · Responsible AI use in research is vital..
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Affiliation(s)
- Emily M Graf
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, Florida
| | - Jordan A McKinney
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, Florida
| | - Alexander B Dye
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, Florida
| | - Lifeng Lin
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona
| | - Luis Sanchez-Ramos
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, Florida
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Garabedian C, Tillouche N, Drumez E, Labreuche J, Dreyfus M, Deruelle P. Outpatient balloon catheter versus expectant management for post-term labor induction in nulliparous women: A randomized trial. J Gynecol Obstet Hum Reprod 2024; 53:102822. [PMID: 38997091 DOI: 10.1016/j.jogoh.2024.102822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 07/04/2024] [Accepted: 07/06/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND Increased use of labor induction has renewed interest in outpatient cervical ripening. Post-term pregnancy (i.e., ≥41 weeks) is a specific situation of increased neonatal risk, including greater risk of perinatal death and adverse perinatal outcomes. While a high proportion of these patients will need induction, outpatient management of this specific population has never been studied. Therefore, our objective was to compare two policies of management of post term pregnancies: the use of a transcervical Foley catheter for outpatient cervical ripening compared with expectant management. METHODS Multicenter, randomized controlled open-label study comparing home induction with a Foley catheter versus expectant management. Inclusion criteria were nulliparous, live singleton fetus in a vertex position, post-term (at 41 + 4 days), requiring cervical ripening (Bishop score <6), intact membranes, and distance home-hospital within 40 min. The primary endpoint was change in Bishop score beetween randomization (41 + 4 days) and consultation (41 + 5 days). RESULTS Forty-five women were included: 21 in the home induction group and 24 in the control group. The study was stopped due to low recruitment. The difference in Bishop score increases one day after randomization approached significance (p = 0.055), with home induction showing a larger change compared with expectant management (Cohen's d = 0.60; 95 % confidence interval [CI] -0.002 to 1.21). Regarding change in Bishop score, 81 % of home induction group patients had a better score at 41 + 5 days versus 52.2 % in the control group (relative risk = 1.55; 95 %CI 0.99 to 2.15). CONCLUSION By specifically evaluating home induction in nulliparous women with post term pregnancies, we observed a Bishop score improvement in the home induction group. These data support further evaluation of induction methods and birth experiences in a larger cohort of this population. TRIAL REGISTRATION The study was registered under European policy (number EudraCT 2015-A01298-41) and on www.clinitrials.gov (number NCT02932319). Date of registration: 13/10/2016, Date of initial participant enrollment: 31/03/2017.
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Affiliation(s)
- C Garabedian
- CHU Lille, Department of obstetrics, F-59000 Lille, France; Univ. Lille, ULR 2694-METRICS, F-59000 Lille, France.
| | - N Tillouche
- CH Valenciennes, Department of obstetrics, 59300 Valenciennes, France
| | - E Drumez
- CHU Lille, Department of statistics, F-59000 Lille, France
| | - J Labreuche
- CHU Lille, Department of statistics, F-59000 Lille, France
| | - M Dreyfus
- CHU Caen, Department of obstetrics, 14000 Caen, France
| | - P Deruelle
- CHU Montpellier, Department of obstetrics, 34000 Caen, France
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Sidebottom AC, Wunderlich WL, Vacquier MC, Drake KA, Goering MP, Hoffman SI, Watson DA, Colicchia LC. Evaluation of an Outpatient Cervical Ripening Program Using Osmotic Dilators and Foley Balloon Catheters. Am J Perinatol 2024. [PMID: 39389557 DOI: 10.1055/a-2413-3171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Abstract
OBJECTIVE This study aimed to describe patient characteristics, satisfaction, and outcome measures for patients undergoing outpatient cervical ripening. STUDY DESIGN A retrospective cohort study using electronic health record data from March 2020 to March 2022 from a large health system. The sample included patients with a low-risk singleton pregnancy undergoing outpatient cervical ripening with either an osmotic dilator or Foley balloon catheter. A subset of patients completed satisfaction surveys. Frequencies and means were used to describe the population and conduct comparisons by device type. Inverse probability of treatment weighted estimates were generated to address baseline differences between patients in the two device groups. RESULTS Outpatient cervical ripening was completed by 120 patients (80 osmotic dilators and 40 Foley balloon catheters). The mean time from insertion to inpatient admission was 16.2 ± 4.8 hours. The mean change in simplified Bishop score (SBS) was 1.8 ± 1.4 and the mean change in dilation was 1.8 ± 1.1 cm. There were no differences in the amount of cervical change by device type. Patients returned earlier than planned 16.7% of the time, primarily for contractions or rupture of membranes. Following outpatient cervical ripening, the time from admission to delivery was 19.9 ± 10.3 hours, with no difference by device type. Vaginal delivery occurred for 74.8% of patients. Patients reported overall satisfaction with the outpatient cervical ripening experience, with the highest satisfaction among those with osmotic dilators. Patients with both device types stated they would recommend outpatient cervical ripening to others, and experienced low levels of stress and discomfort at home prior to hospital admission. CONCLUSION Patients participating in outpatient cervical ripening with osmotic dilators or Foley balloon catheters experienced clinically meaningful changes in dilation and SBSs while at home and reported general satisfaction with the outpatient program experience. KEY POINTS · Outpatient use of osmotic dilators or Foley balloon catheters improved Bishop scores.. · Patient and device complications were comparable to other research findings.. · Patients reported overall satisfaction with outpatient cervical ripening..
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Affiliation(s)
| | | | | | | | | | | | - David A Watson
- Children's of Minnesota Research Institute, Minneapolis, Minnesota
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Velthuijs ELM, Jacod BC, Videler-Sinke L, Kooij C, van Rheenen-Flach LE. Outcome of induction of labour at 41 weeks with foley catheter in midwifery-led care. Midwifery 2024; 135:104026. [PMID: 38781793 DOI: 10.1016/j.midw.2024.104026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/09/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Assess the outcome of induction of labour (IOL) with a Foley catheter in pregnancies at 41 weeks in midwifery-led care setting compared to consultant-led care setting. DESIGN Mixed-methods cohort study at a midwifery - hospital partnership in Amsterdam, the Netherlands. SETTING AND PARTICIPANTS Prospectively, women undergoing IOL in midwifery-led care were recruited at a secondary hospital. This group was compared to a retrospective cohort, in which IOL was exclusively performed under consultant-led care. MEASUREMENTS AND FINDINGS We compared 320 women whose induction started in midwifery-led care to a historical cohort of 320 women induced for the same reason under consultant-led care. Both groups exhibited similar rates of spontaneous vaginal births (64.2 %vs62.5 %). Caesarean section and assisted vaginal birth rates did not significantly differ. Maternal adverse outcomes were comparable, while neonatal adverse outcomes were significantly higher in the midwifery-led care group (8.1 %vs3.8 %; OR 2.27, 95 % CI 1.12-4.58). The use of pain relief was significantly lower in midwife-led care (65.3 %vs75.3 %; OR 0.62, 95 % CI 0.44-0.87). 20.6 % of births occurred in midwife-led care. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE In this single-centre study, spontaneous vaginal birth rates following IOL with a Foley catheter were similar between midwife- and consultant-led care. However, the midwife-led group showed a higher risk of adverse neonatal outcomes, mainly early onset neonatal sepsis, with a minority eventually delivering under midwife-led care. Implications highlight the need for broader research, validation across diverse settings and exploration of patient and healthcare worker perspectives to refine the evolving midwifery-led care model.
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Affiliation(s)
- Eva L M Velthuijs
- Department of Obstetrics and Gynaecology, OLVG, Amsterdam, Netherlands, OLVG, locatie West, Jan Tooropstraat 164, 1061 AE Amsterdam, Netherlands, OLVG, locatie Oost, Oosterpark 9, 1091 AC, Amsterdam, the Netherlands.
| | - Benoit C Jacod
- Department of Obstetrics and Gynaecology, OLVG, Amsterdam, Netherlands, OLVG, locatie West, Jan Tooropstraat 164, 1061 AE Amsterdam, Netherlands, OLVG, locatie Oost, Oosterpark 9, 1091 AC, Amsterdam, the Netherlands
| | - Lizette Videler-Sinke
- Department of Obstetrics and Gynaecology, OLVG, Amsterdam, Netherlands, OLVG, locatie West, Jan Tooropstraat 164, 1061 AE Amsterdam, Netherlands, OLVG, locatie Oost, Oosterpark 9, 1091 AC, Amsterdam, the Netherlands
| | - Caroline Kooij
- EVAA, Eerstelijns Verloskundigen Amsterdam Amstelland, Kastelenstraat 107, 1082EB, Amsterdam, the Netherlands
| | - Leonie E van Rheenen-Flach
- Department of Obstetrics and Gynaecology, OLVG, Amsterdam, Netherlands, OLVG, locatie West, Jan Tooropstraat 164, 1061 AE Amsterdam, Netherlands, OLVG, locatie Oost, Oosterpark 9, 1091 AC, Amsterdam, the Netherlands
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Zhao G, Song G, Liu J. Outpatient cervical ripening with balloon catheters: A Bayesian network meta-analysis of randomized controlled trials. Int J Gynaecol Obstet 2024; 166:607-616. [PMID: 38321823 DOI: 10.1002/ijgo.15409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/07/2024] [Accepted: 01/25/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND One in four labors are induced. The process of cervical ripening can be lengthy and pre-labor hospitalization is required. Outpatient cervical ripening can be an attractive alternative. OBJECTIVES To evaluate the efficacy and safety of outpatient cervical ripening with a balloon catheter compared with inpatient balloon catheter or prostaglandin E2 (PGE2). SEARCH STRATEGY The PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library databases were searched from their inception to October 15, 2022. SELECTION CRITERIA Randomized controlled trials comparing the outpatient balloon catheter with inpatient balloon catheter or inpatient PGE2 for term cervical ripening. DATA COLLECTION AND ANALYSIS Bayesian network meta-analysis was performed. The primary outcome was the cesarean delivery rate. The secondary outcomes included instrumental delivery, the time from intervention-to-birth, oxytocin augmentation, total hospital duration, and maternal/neonatal adverse events. MAIN RESULTS Twenty-nine randomized controlled trials with a total of 6004 participants were identified. No difference in the cesarean delivery rate was revealed among the three interventions. Compared with inpatient balloon catheter, outpatient balloon catheter had shorter total hospital duration (mean difference -8.58, 95% confidence interval -17.02 to -1.10). No differences were revealed in the time from intervention-to-birth, instrumental delivery, postpartum hemorrhage, 5-min Apgar score less than 7, umbilical cord arterial pH less than 7.1, and neonatal intensive care unit admission among the three interventions. CONCLUSIONS Outpatient balloon catheter in low-risk term pregnancies is an available option that could be considered for cervical ripening. The safety and effectiveness are comparable to inpatient cervical ripening methods.
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Affiliation(s)
- Ge Zhao
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, China
| | - Guang Song
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jing Liu
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, China
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Marsdal KE, Sørbye IK, Bernitz S, Sve RET, Ask K, Lukasse M. Outpatient labor induction-Exploring future potential by assessing eligibility in a historical cohort. Acta Obstet Gynecol Scand 2024; 103:1101-1111. [PMID: 38504457 PMCID: PMC11103143 DOI: 10.1111/aogs.14799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 03/21/2024]
Abstract
INTRODUCTION Labor induction rates have increased over the last decades, and in many high-income countries, more than one in four labors are induced. Outpatient management of labor induction has been suggested in low-risk pregnancies to improve women's birth experiences while also promoting a more efficient use of healthcare resources. The primary aim of this paper was to assess the proportion of women in a historical cohort that would have been eligible for outpatient labor induction with oral misoprostol. Second, we wanted to report safety outcomes and assess efficacy outcomes for mothers and infants in pregnancies that met the criteria for outpatient care. MATERIAL AND METHODS Criteria for outpatient labor induction with oral misoprostol were applied to a historical cohort of women with induction of labor at two Norwegian tertiary hospitals in the period January 1, through July 31, 2021. The criteria included low-risk women with an unscarred uterus expecting a healthy, singleton baby in cephalic position at term. The primary outcome was the proportion of women eligible for outpatient labor induction. Secondary outcomes included reasons for ineligibility and, for eligible women, safety and efficacy outcomes. RESULTS Overall, 29.7% of the 1320 women who underwent labor induction in a singleton term pregnancy met the criteria for outpatient labor induction. We identified two serious adverse events that potentially could have occurred outside the hospital if the women had received outpatient care. The mean duration from initiation of labor induction to administration of the last misoprostol was 22.4 h. One in 14 multiparous women gave birth within 3 h after the last misoprostol dose. CONCLUSIONS In this historical cohort, three in ten women met the criteria for outpatient management of labor induction with oral misoprostol. Serious adverse events were rare. The average time span from the initiation of labor induction to the last misoprostol was nearly 24 h. This suggests a potential for low-risk women with an induced labor to spend a substantial period of time at home before labor onset. However, larger studies testing or evaluating labor induction with oral misoprostol as an outpatient procedure are needed to draw conclusions.
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Affiliation(s)
- Kjersti Engen Marsdal
- Faculty of Health Sciences, Department of Nursing and Health PromotionOslo Metropolitan UniversityOsloNorway
- Division of Obstetrics and GynecologyOslo University HospitalOsloNorway
| | - Ingvil Krarup Sørbye
- Division of Obstetrics and GynecologyOslo University HospitalOsloNorway
- Institute of Clinical Medicine, Faculty of MedicineUniversity of OsloOsloNorway
| | - Stine Bernitz
- Faculty of Health Sciences, Department of Nursing and Health PromotionOslo Metropolitan UniversityOsloNorway
- Department of Obstetrics and GynecologyØstfold Hospital TrustGrålumNorway
| | - Ranveig Elise T. Sve
- Division of Obstetrics and GynecologyOslo University HospitalOsloNorway
- Department of Nursing and Social SciencesInstitute of Nursing and Health Sciences, University of South‐Eastern NorwayKongsbergNorway
| | - Kristine Ask
- Department of Nursing and Social SciencesInstitute of Nursing and Health Sciences, University of South‐Eastern NorwayKongsbergNorway
- Department of ObstetricsDrammen HospitalDrammenNorway
| | - Mirjam Lukasse
- Faculty of Health Sciences, Department of Nursing and Health PromotionOslo Metropolitan UniversityOsloNorway
- Department of Nursing and Social SciencesInstitute of Nursing and Health Sciences, University of South‐Eastern NorwayKongsbergNorway
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Kandahari N, Schneider AN, Tucker LYS, Raine-Bennett TR, Mohta VJ. Labor Induction Outcomes with Outpatient Misoprostol for Cervical Ripening among Low-Risk Women. Am J Perinatol 2024; 41:e818-e826. [PMID: 36130669 DOI: 10.1055/a-1948-2779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE In 2012, two Kaiser Permanente Northern California (KPNC) hospitals began offering outpatient cervical ripening with oral misoprostol under a study protocol. We evaluated inpatient time from admission to delivery and adverse maternal and neonatal outcomes associated with outpatient use of misoprostol for cervical ripening among low-risk women with term pregnancies. STUDY DESIGN We conducted a retrospective cohort study comparing three groups: women who received misoprostol (1) outpatient, under a study protocol; (2) inpatient, at the study sites; and (3) inpatient, at all KPNC hospitals. Data were obtained from between 2012 and 2017. The primary outcome was time from inpatient admission to delivery. Secondarily, we evaluated maternal and neonatal outcomes, including the duration and maximum rate of oxytocin administered, rate of cesarean delivery, incidence of chorioamnionitis and blood transfusion, Apgar scores, and neonatal intensive care unit admissions. Demographic and clinical characteristics and outcomes of the outpatient group were compared with both inpatient misoprostol groups using the appropriate statistical test. Variables included in the regression analysis were either statistically significant in the bivariate analyses or have been reported in the literature to be potential confounders: maternal age at admission, race/ethnicity, body mass index, cervical dilation at initial misoprostol, and parity. RESULTS We analyzed data from 10,253 patients: (1) 345 outpatients, under a study protocol; (2) 1,374 inpatients, at the study sites; and (3) 9,908 inpatients, at all the Kaiser hospitals. Women in the outpatient group were more likely to be white than both inpatient groups (63.3 vs. 56.3% at study sites and 47.1% in all hospitals, p = 0.002 and <0.001, respectively); other demographics were clinically comparable. Most women undergoing labor induction were nulliparous; however, a greater proportion in the outpatient group were nulliparous compared with inpatient groups (70.8 vs. 61.8% and 64.3%, p = 0.002 and 0.01). On inpatient admission for delivery, women who received outpatient misoprostol were more likely to have a cervical dilation of ≥3 cm (39.8 vs. 12.5% at study sites and 9.7% at all KPNC hospitals, p < 0.001 for both). The outpatient group had a shorter mean time between admission and delivery (23.6 vs. 29.4 at study sites and 29.8 hours at all KPNC, p < 0.001 for both). The adjusted estimated mean difference between the outpatient and inpatient group at all the Kaiser hospitals in time from admission to delivery was -6.48 hours (p < 0.001), and the adjusted estimated mean difference in cervical dilation on admission was +1.02 cm (p < 0.001). There was no difference in cesarean delivery rates between groups. The rate of chorioamnionitis in the outpatient group was higher compared with inpatients at all hospitals (17.7 vs. 10.6%, p < 0.001), but similar when compared with the inpatients at the study sites (17.7 vs. 15.4%, p = 0.29). CONCLUSION Outpatient use of misoprostol for cervical ripening under the study protocol was associated with reduced inpatient time from admission to delivery compared with inpatient misoprostol. Although there was a higher rate of chorioamnionitis among outpatients under the study protocol compared with inpatients at all hospitals, there was no difference when compared with inpatients at the study sites. There was no difference in rates of cesarean delivery or maternal or neonatal complications with outpatient misoprostol. KEY POINTS · Outpatient misoprostol patients had 6.46 fewer hours from admission to delivery compared with inpatients at all hospitals.. · There was no difference in the rate of cesareans between the outpatient versus inpatient misoprostol groups.. · Other maternal and neonatal complications were low and comparable among outpatients and inpatients who received misoprostol; this study was not large enough to assess rare safety outcomes..
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Affiliation(s)
- Nazineen Kandahari
- School of Medicine, University of California San Francisco, San Francisco, California
- Division of Research, Kaiser Permanente, Oakland, California
- Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Walnut Creek, California
| | - Allison N Schneider
- Department of Obstetrics and Gynecology, George Washington University Medical Faculty Associates, Washington, District of Columbia
| | | | - Tina R Raine-Bennett
- Division of Research, Kaiser Permanente, Oakland, California
- Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Walnut Creek, California
| | - Vanitha J Mohta
- Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Walnut Creek, California
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10
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Zambrano Guevara LM, Buckheit C, Kuller JA, Gray B, Dotters-Katz S. Evidence Based Management of Labor. Obstet Gynecol Surv 2024; 79:39-53. [PMID: 38306291 DOI: 10.1097/ogx.0000000000001225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
Importance Induction of labor (IOL) is a common obstetric intervention. Augmentation of labor and active management of the second stage is frequently required in obstetric practice. However, techniques around labor and induction management vary widely. Evidence-based practice regarding induction and labor management can reduce birth complications such as infection and hemorrhage and decrease rates of cesarean delivery. Objective To review existing evidence on IOL and labor management strategies with respect to preparing for induction, cervical ripening, induction and augmentation, and second stage of labor techniques. Evidence acquisition Review of recent original research, review articles, and guidelines on IOL using PubMed (2000-2022). Results Preinduction, pelvic floor training and perineal massage reduce postpartum urinary incontinence and perineal trauma, respectively. Timely membrane sweeping (38 weeks) can promote spontaneous labor and prevent postterm inductions. Outpatient Foley bulb placement in low-risk nulliparous patients with planned IOL reduces time to delivery. Inpatient Foley bulb use beyond 6 to 12 hours shows no benefit. When synthetic prostaglandins are indicated, vaginal misoprostol should be preferred. For nulliparous patients and those with obesity, oxytocin should be titrated using a high-dose protocol. Once cervical dilation is complete, pushing should begin immediately. Warm compresses and perineal massage decrease risk of perineal trauma. Conclusion and relevance Several strategies exist to assist in successful IOL and promote vaginal delivery. Evidence-based strategies should be used to improve outcomes and decrease risk of complications and cesarean delivery. Recommendations should be shared across interdisciplinary team members, creating a model that promotes safe patient care.
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Affiliation(s)
- Linda M Zambrano Guevara
- Resident, New York University Langone Health, Department of Obstetrics and Gynecology, New York, NY
| | - Caledonia Buckheit
- Former Resident, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC; Physician, Kamm McKenzie OBGYN, Raleigh, NC
| | | | - Beverly Gray
- Associate Professor, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
| | - Sarah Dotters-Katz
- Associate Professor, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
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11
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D'Indinosante M, Vidiri A, Giorgi L, Turrini I, Spanò A, Perelli F, Scatena E, Mattei A, Lanzone A, Scambia G, Cavaliere A. Pre-cervical ripening and hygroscopic cervical dilators in pre-labor induction. J Matern Fetal Neonatal Med 2023; 36:2239422. [PMID: 37574214 DOI: 10.1080/14767058.2023.2239422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Induction of labor (IOL) is becoming a universal topic in Obstetrics, when the risk of continuing a pregnancy outweighs the benefits. Preinduction is a more recent tool to prepare the cervix when the BISHOP-score is low. About one-third of IOL cases require cervical ripening, which is the physical softening, thinning, and dilation of the cervix in preparation for labor and birth. We report a single center experience regarding the use of hygroscopic dilators in the pre-labor phase to obtain cervical ripening before labor induction. MATERIALS & METHODS We conducted a retrospective observational study comparing patient records from the Gynecology and Obstetrics Unit in "Santo Stefano" Hospital in Prato, Tuscany. The inclusion criteria for participants were women who had undergone pre-labor induction because of a BISHOP-score < 3. The gestational age of all the pregnant women was at term (> 37 weeks). RESULTS From January 2022 to April 2022, a total of 581 women delivered at term of gestational age at the Gynecology and Obstetrics Unit in "Santo Stefano" Hospital. Cervical ripening was necessary for 82 women with a Bishop score < 3 and hygroscopic cervical dilators were used in 35/82 (42.7%) patients. All patients showed a change in Bishop-score upon removal of the dilators. All 35 patients (100%) reported an increase in terms of consistency and dilation of the cervix but not in terms of length. None of the patients reported discomfort during the 24 h that they kept the hygroscopic dilators in place. No patients reported uterine tachysystole on cardiotocographic tracing, vaginal bleeding, rupture of membranes or cervical tears. CONCLUSIONS Our results are in line with those in the literature, demonstrating the validity of hygroscopic dilators in cervical maturation of pregnancies at term and their efficacy was again highlighted in terms of both maternal and fetal safety and patient satisfaction.
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Affiliation(s)
- Marco D'Indinosante
- Dipartimento per le Scienze, Della Salute Della Donna, del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Annalisa Vidiri
- Department of Gynecology and Obstetrics, San Giovanni Calibita Fatebenefratelli Hospital-Gemelli Hospital, Isola Tiberina, Rome, Italy
| | - Laura Giorgi
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, Prato, Italy
| | - Irene Turrini
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, Prato, Italy
| | - Amelia Spanò
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federica Perelli
- Division of Gynaecology and Obstetrics, Santa Maria Annunziata Hospital, USL Toscana Centro, Florence, Italy
| | - Elisa Scatena
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, Prato, Italy
| | - Alberto Mattei
- Division of Gynaecology and Obstetrics, Santa Maria Annunziata Hospital, USL Toscana Centro, Florence, Italy
| | - Antonio Lanzone
- Department of Science of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giovanni Scambia
- Department of Science of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Annafranca Cavaliere
- Department of Gynecology and Obstetrics, San Giovanni Calibita Fatebenefratelli Hospital-Gemelli Hospital, Isola Tiberina, Rome, Italy
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12
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Bekele D, Asfaw M, Nigatu B, Kebede B, Tolu LB, Abdosh AA, Sium AF. A randomized controlled trial of sequential vs simultaneous use of Foley balloon catheter and oxytocin for induction of labor in nulliparous pregnant women. AJOG GLOBAL REPORTS 2023; 3:100252. [PMID: 37645648 PMCID: PMC10461236 DOI: 10.1016/j.xagr.2023.100252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
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.
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Affiliation(s)
- Delayehu Bekele
- Department of Obstetrics and Gynecology, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mariamawit Asfaw
- Department of Obstetrics and Gynecology, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Balkachew Nigatu
- Department of Obstetrics and Gynecology, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Birhanu Kebede
- Department of Obstetrics and Gynecology, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Lemi Belay Tolu
- Department of Obstetrics and Gynecology, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Abraham Fessehaye Sium
- Department of Obstetrics and Gynecology, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
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13
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Hallén N, Amini M, Wide-Swensson D, Herbst A. Outpatient vs inpatient induction of labor with oral misoprostol: A retrospective study. Acta Obstet Gynecol Scand 2023; 102:605-611. [PMID: 36965000 PMCID: PMC10072241 DOI: 10.1111/aogs.14550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/21/2023] [Accepted: 02/25/2023] [Indexed: 03/27/2023]
Abstract
INTRODUCTION Induction of labor is one of the most common obstetrical procedures today, with a successively rising rate. With a limited number of hospital beds, the option of starting induction at home has gained increasing attention. The primary aim of this study was to compare the proportion of women achieving vaginal delivery and the duration of hospital stay before delivery in induction of labor with oral misoprostol starting at home and induction with oral misoprostol at the hospital, in a low-risk population. MATERIAL AND METHODS Women with home induction (n = 282) were individually matched to controls induced at the hospital during the same time period regarding parity, age, body mass index, labor unit and indication for induction. RESULTS The rates of vaginal birth were similar in outpatients and inpatients (84.8% vs 86.2%; p = 0.5). Time from hospital admission to delivery in the outpatient group was significantly shorter than in the inpatient group (12.8 vs 20.6 h; p < 0.001), as was total hospital stay (2 vs 3 days; p < 0.001). There were no significant differences between the groups in neonatal or maternal outcomes. One patient undergoing outpatient induction had an unplanned home birth. CONCLUSIONS Starting induction at home reduced the time spent in hospital without affecting the vaginal delivery rate. Although underpowered to assess safety, this study did not show any differences in adverse maternal and perinatal outcomes between inpatients and outpatients. Further research is needed to evaluate the safety of outpatient induction of labor with misoprostol.
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Affiliation(s)
- Natalie Hallén
- Institution for Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Mahdi Amini
- Institution for Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden
| | - Dag Wide-Swensson
- Institution for Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden
| | - Andreas Herbst
- Institution for Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden
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14
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Seasely AR, Xue Y, Ausbeck EB, Jauk VC, Blanchard CT, Files P, Kuper SC, Casey BM, Szychowski JM, Harper LM, Tita AT, Subramaniam A. Outpatient Foley Catheter for Induction of Labor in Obese Nulliparous Patients: A Secondary Analysis of OFFSITE II Randomized Controlled Trial. Am J Perinatol 2022; 40:807-810. [PMID: 36477716 DOI: 10.1055/s-0042-1759645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE In the OFFSITE II randomized controlled trial, outpatient cervical ripening with a Foley catheter (CF) in nulliparous patients undergoing elective induction of labor (eIOL) shortened the time from admission to delivery. Given that patients with obesity have protracted labor and higher rates of failed IOL, we sought to determine if outpatient ripening with a CF may be even more beneficial for this high-risk group. STUDY DESIGN We performed a secondary analysis of the OFFSITE II randomized controlled trial. For this analysis, all patients from the primary trial were classified by their intervention assignment (inpatient vs. outpatient) and also by their admission body mass index (BMI) class (BMI ≥ 30 and BMI < 30 kg/m2). The primary outcome was time from labor and delivery (L&D) admission to delivery. Secondary outcomes included cesarean delivery, time from admission to hospital discharge, and rates of clinically diagnosed chorioamnionitis and endometritis. RESULTS In patients with BMI ≥ 30, the primary outcome, time from admission to delivery, (18.0 [13.5-20.9] vs. 20.4 [16.6-31.3] hours, p = 0.01), as well as total hospitalization length (3.2 [2.5-3.3] vs. 3.4 [3.1-4.3] days, p = 0.02) were shorter in the outpatient group. There were no differences in rates of chorioamnionitis or endometritis in outpatient compared with inpatient CF. Furthermore, in those with a BMI ≥ 30, the cesarean rate was significantly lower with outpatient CF (19.4% vs. 44.7%, p = 0.03); it was not statistically different in patients with BMI < 30. CONCLUSION In this exploratory retrospective secondary analysis of the OFFSITE II randomized control trial, we found that in patients with BMI ≥ 30 undergoing eIOL, outpatient CF was associated with a lower time from L&D admission until delivery. This was also associated with a shorter time of total hospital duration and decreased the rate of cesarean, a benefit not detected in the overall analysis presented in the primary study. In nulliparas undergoing induction of labor, ripening with outpatient cervical Foley may even more significantly reduce labor duration, total hospital duration, and the rate of cesarean in patients with obesity. KEY POINTS · Outpatient CF was associated with a lower time from L&D admission until delivery in obese nulliparas.. · Outpatient CF was associated with a shorter time of total hospital duration in obese nulliparas.. · Outpatient CF was associated with a decreased rate of cesarean birth in obese nulliparas..
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Affiliation(s)
- Angela R Seasely
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yumo Xue
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth B Ausbeck
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Victoria C Jauk
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christina T Blanchard
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pamela Files
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Spencer C Kuper
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brian M Casey
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeff M Szychowski
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lorie M Harper
- Department of Women's Health, University of Texas at Austin, Dell Medical School, Austin, Texas
| | - Alan T Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Akila Subramaniam
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
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15
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Outpatient Compared With Inpatient Preinduction Cervical Ripening Using a Synthetic Osmotic Dilator: A Randomized Clinical Trial. Obstet Gynecol 2022; 140:584-590. [PMID: 36083097 PMCID: PMC9484761 DOI: 10.1097/aog.0000000000004942] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/08/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To assess whether outpatient cervical ripening with a synthetic osmotic dilator shortens the length of hospital stay in term pregnancies undergoing labor induction. METHODS Pregnant participants scheduled for labor induction at term with unfavorable cervix (less than 3-cm dilated and less than 60% effaced) and not requiring inpatient maternal or fetal monitoring were consented, and synthetic osmotic dilator rods were inserted on the day of scheduled induction. After reassuring fetal heart tracing, patients randomized to the outpatient group were asked to return 12 hours after insertion or sooner if needed. Those randomized to the inpatient group remained in the hospital. After the first round of ripening, additional ripening, oxytocin, and labor management were left up to the clinical health care professionals. The primary outcome was the proportion of participants with hospital stays longer than 48 hours. We estimated that a sample size of 338 would provide 85% power to detect a 30% difference between groups. RESULTS From November 2018 to November 2021, 339 participants were randomized (171 inpatient, 167 outpatient, one withdrawal). Four patients in the outpatient group were admitted before12 hours for suspected labor and rupture of membranes, and 19 in the inpatient group had the device removed before 12 hours. The proportion of participants with hospital stays longer than 48 hours was lower in the outpatient group compared with the inpatient group (89 [53%] vs 152 [89%], relative risk [RR] 0.60, 95% CI 0.52-0.70). Patients in the outpatient group had a shorter total length of stay and time from admission to active labor. They were more likely to have a vaginal delivery within 24 hours of admission and were less likely to receive analgesics during ripening. Route of delivery and other maternal and neonatal outcomes were not significantly different between groups. CONCLUSION Outpatient cervical ripening with a cervical osmotic dilator decreased hospital stay compared with inpatient ripening, without significant adverse outcomes. FUNDING SOURCE Medicem Technology s.r.o., Czech Republic. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT03665688.
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16
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Outpatient Cervical Ripening with Balloon Catheters: A Systematic Review and Meta-analysis. Obstet Gynecol 2022; 139:255-268. [PMID: 34991144 DOI: 10.1097/aog.0000000000004644] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/28/2021] [Indexed: 11/26/2022]
Abstract
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.
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17
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A double-blinded randomized controlled trial on the effects of increased intravenous hydration in nulliparas undergoing induction of labor. Am J Obstet Gynecol 2022; 227:269.e1-269.e7. [PMID: 35114186 DOI: 10.1016/j.ajog.2022.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/30/2021] [Accepted: 01/07/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Rates of labor induction are increasing, raising concerns related to increased healthcare utilization costs. High-dose intravenous fluid (250 cc/h) has been previously demonstrated to shorten the time to delivery in nulliparous individuals in spontaneous labor. Whether or not this relationship exists among individuals undergoing induction of labor is unknown. OBJECTIVE Our study aimed to evaluate the effect of high-dose intravenous hydration on time to delivery among nulliparous individuals undergoing induction of labor. STUDY DESIGN Nulliparous individuals presenting for induction of labor with a Bishop score of ≤6 (with and without rupture of membranes) were randomized to receive either 125 cc/h or 250 cc/h of normal saline. The primary outcome was length of labor (defined as time from initiation of study fluids to delivery). Both time to overall delivery and vaginal delivery were evaluated. Secondary outcomes included the lengths of each stage of labor, the percentage of individuals delivering within 24 hours, and maternal and neonatal outcomes, including cesarean delivery rate. RESULTS A total of 180 individuals meeting inclusion criteria were enrolled and randomized. Baseline demographic characteristics were similar between groups; however, there was a higher incidence of diabetes mellitus in the group receiving 125 cc/h. Average length of labor was similar between groups (27.6 hours in 250 cc/h and 27.8 hours in 125 cc/h), as was the length of each stage of labor. Cox regression analysis did not demonstrate an effect of fluid rate on time to delivery. Neither the admission Bishop score, body mass index, nor other demographic characteristics affected time to delivery or vaginal delivery. There were no differences in maternal or neonatal outcomes, including overall cesarean delivery rate, clinically apparent iatrogenic intraamniotic infection, Apgar scores, need for neonatal phototherapy, or neonatal intensive care unit stay. CONCLUSION There were no observed differences in the length of labor or maternal or neonatal outcomes with the administration of an increased rate of intravenous fluids among nulliparous individuals undergoing induction of labor.
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18
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Saunders SJ, Grisamore JL, Wong T, Torrejon Torres R, Saunders R, Einerson B. Moving preinduction cervical ripening to a lower acuity inpatient setting using the synthetic hygroscopic cervical dilator: a cost-consequence analysis for the United States. J Med Econ 2022; 25:1185-1198. [PMID: 36274625 DOI: 10.1080/13696998.2022.2136854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
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.
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Affiliation(s)
| | - Jody L Grisamore
- Labor and Delivery, Northwestern Medicine Prentice Women's Hospital, Chicago, IL, USA
| | | | | | | | - Brett Einerson
- Maternal-Fetal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Gupta J, Baev O, Duro Gomez J, Garabedian C, Hellmeyer L, Mahony R, Maier J, Parizek A, Radzinsky V, Stener Jorgensen J, Britt Wennerholm U, Carlo Di Renzo G. Mechanical methods for induction of labor. Eur J Obstet Gynecol Reprod Biol 2021; 269:138-142. [PMID: 34740471 DOI: 10.1016/j.ejogrb.2021.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - Oleg Baev
- Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | | | - Charles Garabedian
- Division of Obstetrics, Hospitalier Régional Universitaire de Lille, Lille, France
| | - Lars Hellmeyer
- Department of Gynecology and Obstetrics, Vivantes International Medicine, Am Nordgraben 2, 13509 Berlin - Germany
| | | | - Josefine Maier
- Department of Gynecology and Obstetrics, Vivantes International Medicine, Am Nordgraben 2, 13509 Berlin - Germany
| | - Antonin Parizek
- Department of Obstetrics and Gynaecology of the 1st Faculty of Medicine and General University Hospital, Prague, Czech Rep
| | - Viktor Radzinsky
- People's Friendship University of Russia, 6, Miklukho-Maklaya st., Moscow
| | | | - Ulla Britt Wennerholm
- Department of Obstetrics and Gynecology, The University of Gothenburg, Gothenburg, Sweden
| | - Gian Carlo Di Renzo
- Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy
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Doulaveris G, Vani K, Saccone G, Chauhan SP, Berghella V. Number and quality of randomized controlled trials in obstetrics published in the top general medical and obstetrics and gynecology journals. Am J Obstet Gynecol MFM 2021; 4:100509. [PMID: 34656731 DOI: 10.1016/j.ajogmf.2021.100509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/26/2021] [Accepted: 10/10/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND There has been an increasing number of randomized controlled trials published in obstetrics and maternal-fetal medicine to reduce biases of treatment effect and to provide insights on the cause-effect of the relationship between treatment and outcomes. OBJECTIVE This study aimed to identify obstetrical randomized controlled trials published in top weekly general medical journals and monthly obstetrics and gynecology journals, to assess their quality in reporting and identify factors associated with publication in different journals. STUDY DESIGN The 4 weekly medical journals with the highest 2019 impact factor (New England Journal of Medicine, The Lancet, The Journal of the American Medical Association, and British Medical Journal), the top 4 monthly obstetrics and gynecology journals with obstetrics-related research (American Journal of Obstetrics & Gynecology, Ultrasound in Obstetrics & Gynecology, Obstetrics & Gynecology, and the British Journal of Obstetrics and Gynaecology), and the American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine were searched for obstetrical randomized controlled trials in the years 2018 to 2020. The primary outcome was the number of obstetrical randomized controlled trials published in the obstetrics and gynecology journals vs the weekly medical journals and the percentage of trials published, overall and per journal. The secondary outcomes included the proportion of positive vs negative trials overall and per journal and the assessment of the study characteristics of published trials, including quality assessment criteria. RESULTS Of the 4024 original research articles published in the 9 journals during the 3-year study period, 1221 (30.3%) were randomized controlled trials, with 137 (11.2%) randomized controlled trials being in obstetrics (46 in 2018, 47 in 2019, and 44 studies in 2020). Furthermore, 33 (24.1%) were published in weekly medical journals, and 104 (75.9%) were published in obstetrics and gynecology journals. The percentage of obstetrical randomized controlled trials published ranged from 1.5% to 9.6% per journal. Overall, 34.3% of obstetrical trials were statistically significant or "positive" for the primary outcome. Notably, 24.8% of the trials were retrospectively registered after the enrollment of the first study patient. Trials published in the 4 weekly medical journals enrolled significantly more patients (1801 vs 180; P<.001), received more often funding from the federal government (78.8% vs 35.6%; P<.001), and were more likely to be multicenter (90.9% vs 42.3%; P<.001), non-United States based (69.7% vs 49.0%; P=.03), and double blinded (45.5% vs 18.3%; P=.003) than trials published in the obstetrics and gynecology journals. There was no difference in study type (noninferiority vs superiority) and trial quality characteristics, including pretrial registration, ethics approval statement, informed consent statement, and adherence to the Consolidated Standards of Reporting Trials guidelines statement between studies published in weekly medical journals and studies published in obstetrics and gynecology journals. CONCLUSION Approximately 45 trials in obstetrics are being published every year in the highest impact journals, with one-fourth being in the weekly medical journals and the remainder in the obstetrics and gynecology journals. Only about a third of published obstetrical trials are positive. Trials published in weekly medical journals are larger, more likely to be funded by the government, multicenter, international, and double blinded. Quality metrics are similar between weekly medical journals and obstetrics and gynecology journals.
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Affiliation(s)
- Georgios Doulaveris
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Drs Doulaveris and Vani).
| | - Kavita Vani
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Drs Doulaveris and Vani)
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Dr Saccone)
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Dr Chauhan)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (Dr Berghella)
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21
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Wilkinson C. Outpatient labour induction. Best Pract Res Clin Obstet Gynaecol 2021; 77:15-26. [PMID: 34556409 DOI: 10.1016/j.bpobgyn.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/26/2022]
Abstract
The inexorable rise in induction rates over the past two decades, in parallel with increasing medical costs and pressure to reduce length of stay, has led to marked logistic difficulties for health care workers, managers and planners. Maternity services are being overwhelmed by the need to allocate staff and delivery suite space for the scheduling and undertaking of induction processes, rather than focussing care for women in spontaneous labour. Induction of labour according to the majority of current protocols and guidelines necessitates increased length of stay and relatively aggressive use of oxytocin (to reduce the time expended in the labour ward from artificial rupture of membranes (AROM) to establishment of labour). This increased oxytocin usage requires increased use of continuous electronic foetal monitoring, and may also increase epidural usage, further increasing the complexity of labour for the woman and her health care workers. Outpatient care after cervical priming and even outpatient care after AROM may help to ease these pressures and may reduce the medicalisation of the birth experience when induction is indicated, with a potential to reduce oxytocin use and associated interventions. If the period between cervical priming to AROM is managed as outpatient care, then the woman may be able to find better psychological and social support at home, as well as maintain autonomy and get better rest prior to the onset of labour. Inpatient AROM could also be followed by outpatient care until the pregnant person returns to the hospital, either in spontaneous labour, or for initiation of syntocinon after 12-18 h. High-quality research has already demonstrated that outpatient care for cervical ripening is acceptable to mothers and caregivers, has economic benefits and has an acceptable safety profile in appropriately selected low-risk inductions.
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Affiliation(s)
- Chris Wilkinson
- Women's and Children's Hospital, North Adelaide, 5006, South Australia, Australia; Robinson Institute, University of Adelaide, Adelaide, 5000, South Australia, Australia.
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22
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Hamdan M, Shuhaina S, Hong JGS, Vallikkannu N, Zaidi SN, Tan YP, Tan PC. Outpatient vs inpatient Foley catheter induction of labor in multiparas with unripe cervixes: A randomized trial. Acta Obstet Gynecol Scand 2021; 100:1977-1985. [PMID: 34462906 DOI: 10.1111/aogs.14247] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/09/2021] [Accepted: 08/16/2021] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Mukhri Hamdan
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shuib Shuhaina
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jesrine Gek Shan Hong
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Narayanan Vallikkannu
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Syeda Nureena Zaidi
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yi Pin Tan
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Peng Chiong Tan
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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23
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Saunders SJ, Saunders R, Wong T, Saad AF. Out-of-Hospital Cervical Ripening With a Synthetic Hygroscopic Cervical Dilator May Reduce Hospital Costs and Cesarean Sections in the United States-A Cost-Consequence Analysis. Front Public Health 2021; 9:689115. [PMID: 34222185 PMCID: PMC8249762 DOI: 10.3389/fpubh.2021.689115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/18/2021] [Indexed: 11/22/2022] Open
Abstract
Objective: Out-of-hospital (outpatient) cervical ripening prior to induction of labor (IOL) is discussed for its potential to decrease the burden on hospital resources. We assessed the cost and clinical outcomes of adopting an outpatient strategy with a synthetic hygroscopic cervical dilator, which is indicated for use in preinduction cervical ripening. Methods: We developed a cost-consequence model from the hospital perspective with a time period from IOL to post-delivery discharge. A hypothetical cohort of women to undergo IOL at term with an unfavorable cervix (all risk levels) were assessed. As the standard of care (referred to as IP-only) all women were ripened as inpatients using the vaginal PGE2 insert or the single-balloon catheter. In the comparison (OP-select), 50.9% of low-risk women (41.4% of the study population) received outpatient cervical ripening using a synthetic hygroscopic cervical dilator and the remaining women were ripened as inpatients as in the standard of care. Model inputs were sourced from a structured literature review of peer-reviewed articles in PubMed. Testing of 2,000 feasible scenarios (probabilistic multivariate sensitivity analysis) ascertained the robustness of results. Outcomes are reported as the average over all women assessed, comparing OP-select to IP-only. Results: Implementing OP-select resulted in hospital savings of US$689 per delivery, with women spending 1.48 h less time in the labor and delivery unit and 0.91 h less in the postpartum recovery unit. The cesarean-section rate was decreased by 3.78 percentage points (23.28% decreased to 19.50%). In sensitivity testing, hospital costs and cesarean-section rate were reduced in 91% of all instances. Conclusion: Our model analysis projects that outpatient cervical ripening has the potential to reduce hospital costs, hospital stay, and the cesarean section rate. It may potentially allow for better infection-prevention control during the ongoing COVID-19 pandemic and to free up resources such that more women might be offered elective IOL at 39 weeks.
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Affiliation(s)
| | | | - Tess Wong
- Medicem, Inc., Boston, MA, United States
| | - Antonio F Saad
- Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
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24
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McDonagh M, Skelly AC, Tilden E, Brodt ED, Dana T, Hart E, Kantner SN, Fu R, Hermesch AC. Outpatient Cervical Ripening: A Systematic Review and Meta-analysis. Obstet Gynecol 2021; 137:1091-1101. [PMID: 33752219 PMCID: PMC8011513 DOI: 10.1097/aog.0000000000004382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/19/2021] [Accepted: 02/24/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the comparative effectiveness and potential harms of cervical ripening in the outpatient compared with the inpatient setting, or different methods of ripening in the outpatient setting alone. DATA SOURCES Searches for articles in English included MEDLINE, EMBASE, CINAHL, Cochrane Library, ClinicalTrials.gov, and reference lists (up to August 2020). METHODS OF STUDY SELECTION Using predefined criteria and DistillerSR software, 10,853 citations were dual-reviewed for randomized controlled trials (RCTs) and cohort studies of outpatient cervical ripening using prostaglandins and mechanical methods in pregnant women at or beyond 37 weeks of gestation. TABULATION, INTEGRATION, AND RESULTS Using prespecified criteria, study data abstraction and risk of bias assessment were conducted by two reviewers, random-effects meta-analyses were conducted and strength of evidence was assessed. We included 30 RCTs and 10 cohort studies (N=9,618) most generalizable to women aged 25-30 years with low-risk pregnancies. All findings were low or insufficient strength of evidence and not statistically significant. Incidence of cesarean delivery was not different for any comparison of inpatient and outpatient settings, or comparisons of different methods in the outpatient setting (most evidence available for single-balloon catheters and dinoprostone). Harms were inconsistently reported or inadequately defined. Differences were not found for neonatal infection (eg, sepsis) with outpatient compared with inpatient dinoprostone, birth trauma (eg, cephalohematoma) with outpatient compared with inpatient single-balloon catheter, shoulder dystocia with outpatient dinoprostone compared with placebo, maternal infection (eg, chorioamnionitis) with outpatient compared with inpatient single-balloon catheters or outpatient prostaglandins compared with placebo, and postpartum hemorrhage with outpatient catheter compared with inpatient dinoprostone. Evidence on misoprostol, hygroscopic dilators, and other outcomes (eg, perinatal mortality and time to vaginal birth) was insufficient. CONCLUSION In women with low-risk pregnancies, outpatient cervical ripening with dinoprostone or single-balloon catheters did not increase cesarean deliveries. Although there were no clear differences in harms when comparing outpatient with inpatient cervical ripening, the certainty of evidence is low or insufficient to draw definitive conclusions. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42020167406.
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Affiliation(s)
- Marian McDonagh
- Pacific Northwest Evidence-Based Practice Center, Medical Informatics and Clinical Epidemiology, the Department of Nurse-Midwifery, School of Nursing, the School of Public Health, Portland State University, and Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon; and Aggregate Analytics, Fircrest, Washington
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25
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Cochrane Review Summaries-January 2021. Obstet Gynecol 2021; 137:173-175. [PMID: 33278276 DOI: 10.1097/aog.0000000000004217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In this month's issue, the journal continues to bring new insights from Cochrane Systematic Reviews to the readers of Obstetrics & Gynecology. This month, we highlight two interventions related to labor induction and initiation as well as a review of adhesion-prevention techniques in gynecologic surgery. The summaries are published below. The complete references with hyperlinks are listed in Box 1.
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26
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A Tribute to Nancy C. Chescheir, MD. Obstet Gynecol 2021; 137:1-2. [PMID: 33278282 DOI: 10.1097/aog.0000000000004215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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