Induction of labour using prostaglandin E 2 as an inpatient versus balloon catheter as an outpatient: a multicentre randomised controlled trial

Outpatient cervical ripening with balloon catheters: A Bayesian network meta-analysis of randomized controlled trials

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.

Effectiveness and Safety of the Double Intracervical Balloon vs Dinoprostone in Patients with Previous Cesarean Section

To compare effectiveness and safety of the Cook's balloon with vaginal dinoprostone to induce labor in patients with previous cesarean section. Observational, and retrospective study that included pregnant women at ≥ 37 weeks' gestation, with unfavorable cervix, singleton pregnancy, intact membranes, and a previous cesarean section, who had undergone labor induction in the period 2014-2019. 170 patients (86 balloon-84 dinoprostone) were analyzed. The proportion of women achieving vaginal delivery within 24 h was higher in the dinoprostone than in double-balloon group (RR, 3.24; 95% CI, 1.36-7.72). No significant differences were detected in the first 48 h in vaginal deliveries (P = .749) or in cesarean section rates (P = .634). Nor were there differences in maternal or fetal safety profiles. A body mass index > 35 increased the risk of cesarean section by 1.53 times (P = .017) and a Bishop's test score < 3 by 1.91 times (P = .009). A vaginal delivery following a cesarean section decreased the probability of another cesarean section by 0.46 times (P = .039). Labor induction with vaginal dinoprostone achieves better vaginal delivery rates in the first 24 h vs Cook's balloon. While the difference in uterine rupture rate did not reach significance, this was higher in women receiving prostaglandin.

Exploring the Limits of Artificial Intelligence for Referencing Scientific Articles

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..

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

OBJECTIVE

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

METHODS

Trials comparing these two methods, published or unpublished up to July 2023, in French or English were searched for in the PubMed, Cochrane Library and ClinicalTrial.govs datasets.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

RESULT

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

CONCLUSION

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

Efficacy and safety of double balloon catheter and dinoprostone for labor induction in multipara at term

PURPOSE

The aim of this study was to comparatively assess the efficacy and safety of double balloon catheter (DBC) and dinoprostone as labor-inducing agents just for multipara at term.

METHODS

A retrospective cohort study was conducted among multipara at term with a Bishop score < 6 who needed planned labor induction from January 1, 2020, to December 30, 2020 in Maternal and Child Health Hospital of Hubei province, Tongji Medical College, Huazhong University of Science and Technology. They were divided into DBC group and dinoprostone group, respectively. Baseline maternal data, maternal and neonatal outcomes were recorded for statistical analysis. Total vaginal delivery rate, rate of vaginal delivery within 24 h, rate of uterine hyperstimulation combined with abnormal fetal heart rate(FHR) were regarded as the primary outcome variables. The difference between groups was considered statistically significant when p value < 0.05.

RESULTS

A total of 202 multiparas was included for analysis (95 women in DBC group vs 107 women in dinoprostone group). There were no significant differences in total vaginal delivery rate and rate of vaginal delivery within 24 h between groups. Uterine hyperstimulation combined with abnormal FHR occurred exclusively in dinoprostone group.

CONCLUSION

DBC and dinoprostone seem to be equally effective, while, DBC seems to be safer than dinoprostone.

Factors associated with spontaneous vaginal birth in nulliparous women: A descriptive systematic review

PROBLEM

Spontaneous vaginal birth (SVB) rates for nulliparous women are declining internationally.

BACKGROUND

There is inadequate understanding of factors affecting this trend overall and limited large-scale responses to improve women's opportunity to birth spontaneously.

AIM

To undertake a descriptive systematic review identifying factors associated with spontaneous vaginal birth at term, in nulliparous women with a singleton pregnancy.

METHODS

Quantitative studies of all designs, of nulliparous women with a singleton pregnancy and cephalic presentation, who experienced a SVB at term were included. Nine databases were searched (inception to October 2022). Two reviewers undertook quality appraisal; Randomised Controlled Trials (RCTs) with high risk of bias (ROB 2.0) and other designs with (QATSDD) scoring ≤ 50% were excluded.

FINDINGS

Data were abstracted from 90 studies (32 RCTs, 39 cohort, 9 cross-sectional, 4 prevalence, 5 case control, 1 quasi-experimental). SVB rates varied (13%-99%). Modifiable factors associated with SVB included addressing fear of childbirth, low impact antenatal exercise, maternal positioning during second-stage labour and midwifery led care. Complexities arising during pregnancy and regional analgesia were shown to decrease SVB and other interventions, such as routine induction of labour were equivocal.

DISCUSSION

Antenatal preparation (low impact exercise, childbirth education, addressing fear of childbirth) may increase SVB, as does midwifery continuity-of-care. Intrapartum strategies to optimise labour progression emerged as promising areas for further research.

CONCLUSION

Declining SVB rates may be improved through multi-factorial approaches inclusive of maternal, fetal and clinical care domains. However, the variability of SVB rates testifies to the complexity of the issue.

Accidental rupture of membranes and neonatal infection after labor induction with silicone or latex balloon catheters: A retrospective cohort study

OBJECTIVE(S)

Accidental rupture of membranes (acROM), an insertion-related complication of the balloon catheter for labor induction, may prolong the duration of ruptured membranes. Prolonged rupture of membranes is associated with an increased risk of intra-uterine infection with possibly neonatal infection as result. Little is known about safety profiles of different catheters regarding the occurrence of these complications. This study compares the incidence of neonatal early-onset sepsis (EOS) and acROM in women receiving either silicone or latex balloon catheters.

STUDY DESIGN

A retrospective cohort study was performed including 2200 women (silicone balloon catheter, n = 1100 vs. latex balloon catheter, n = 1100). The primary outcomes were the incidence of acROM, and suspected and proven neonatal EOS. Secondary outcomes were: prolonged rupture of membranes, intrapartum fever, pre- or postnatal neonatal exposure to antibiotics, and perinatal outcomes. A subgroup analysis was performed between women with and without acROM.

RESULTS

No statistically significant difference with regard to suspected or proven EOS was seen between the silicone and latex groups. The acROM rate was significantly higher in the silicone group compared to the latex group (2.9 % and 0.3 %, p < 0.01). Prolonged rupture of membranes was significantly more common in the silicone group compared to the latex group (5.0 % and 2.4 %, p < 0.01), as was the use of intrapartum antibiotics (12.7 % and 9.6 %, p = 0.02). Neonates were significantly more often exposed to pre- or postnatal antibiotics in the silicone group compared to the latex group (17.6 % and 13.6 %, p = 0.01). Subgroup analysis showed significantly more suspected and proven neonatal EOS when catheter-insertion was complicated with acROM (11.4 % and 20.0 %), compared to cases without acROM (3.8 % and 2.5 %), irrespective of the type of catheter used.

CONCLUSION(S)

The use of silicone balloon catheters for labor induction results in higher rates of acROM, prolonged rupture of membranes and use of intrapartum antibiotics, compared to latex balloon catheters. No statistically significant differences were found in the occurrence of suspected or proven neonatal EOS, however neonates from the silicone group were more often exposed to pre- or postnatal antibiotics. When acROM occurs, irrespective of type of catheter used, suspected and proven neonatal EOS was seen more often.

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.

Number and quality of randomized controlled trials in obstetrics published in the top general medical and obstetrics and gynecology journals

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.

Outpatient labour induction

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.

Towards an evidence-based approach to optimize the success of labour induction

Induction of labour is a two-step process involving cervical ripening and the initiation of uterine contractions, with the goal of achieving vaginal birth. To optimize the chance of a safe and timely vaginal birth, the process of induction of labour should be evidence based and individualized to the given person and situation. In this study, we lay out a framework for how this should be done, emphasizing on careful clinical assessment and planning, flexibility in the strategy of induction, patience during the ripening and latent phases of labour, and thoughtful consideration regarding changing the strategy if active labour is not initially achieved. The goal of this review is to present the current evidence on this topic in the form of a user-friendly protocol that can be easily adapted to institutional practice.

Induction of labour in low-resource settings

Due to the disparity in resource availability between low- and high-resource settings, practice recommendations relevant to high-income countries are not always relevant and often need to be adapted to low-resource settings. The adaptation applies to induction of labour (IOL) which is an obstetric procedure that deserves special attention because it involves the initiation of a process that requires regular and frequent monitoring of the mother and foetus by experienced healthcare professionals. Lack of problem recognition and/or substandard care during IOL may result in harm with long-term sequelae. In this article, the authors discuss unique challenges such as insufficient resources (including staff, midwives, doctors, equipment, and medications) that result in occasional inadequate patient monitoring and/or delayed interventions during IOL in low-resource settings. We also discuss modifications in indications and methods for IOL, issues related to human immunodeficiency virus (HIV) infections, the feasibility of outpatient induction, clinical protocols and a minimum dataset for quality improvement projects. Overall, the desire to achieve a vaginal birth with IOL should not cloud the necessity to observe the required safety measures and implement necessary interventions; given that childbirth practices are the major determinants of pregnancy outcomes and patient satisfaction.

Outpatient Cervical Ripening: A Systematic Review and Meta-analysis

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.

Induction of labor using balloon catheter as an outpatient versus prostaglandin as an inpatient: A cost-effectiveness analysis

OBJECTIVE

The aim of this work was to assess the cost-effectiveness of induction of labor with outpatient balloon catheter cervical priming versus inpatient prostaglandin vaginal gel or tape.

STUDY DESIGN

Economic evaluation alongside a multi-centre, randomized controlled trial at eight Australian maternity hospitals. The trial reported on 448 women with live singleton term pregnancies, undergoing induction of labor for low-risk indications between September 2015 and October 2018. An economic decision tree model was designed from a health services perspective from time of induction of labor to hospital discharge. Sensitivity and subgroup analyses were performed to test the robustness of model outcomes. We estimated resource use, collected data on health outcomes (using EQ-5D-3 L questionnaire) and reported cost (Australian Dollars) per quality-adjusted life year gained, incremental cost-effect ratio and net monetary benefit.

RESULTS

Deterministic analysis showed lower mean costs ($7294 versus $7585) in the outpatient-balloon (n = 205) compared to the inpatient-prostaglandin group (n = 243), with similar health outcomes (0.75 vs 0.74 quality-adjusted life years gained) and overall higher net monetary benefit ($30,054 vs $29,338). In probabilistic analyses outpatient-balloon induction of labor was cost-effective in 55.3 % of all simulations and 59.1 % for women with favourable cervix (modified Bishop score >3) and 64.5 % for nulliparous women.

CONCLUSIONS

Outpatient-balloon induction of labor may be cost-saving compared to inpatient induction of labor with prostaglandin and is most likely to be cost-effective for nulliparous women, but more research is warranted in other settings to explore the generalisability of results.

Outpatient Induction of Labor - Are Balloon Catheters an Appropriate Method?

As the number of labor inductions in high-income countries has steadily risen, hospital costs and the additional burden on obstetric staff have also increased. Outpatient induction of labor is therefore becoming increasingly important. It has been estimated that 20 – 50% of all pregnant women requiring induction would be eligible for outpatient induction. The use of balloon catheters in patients with an unripe cervix has been shown to be an effective and safe method of cervical priming. Balloon catheters are as effective as the vaginal administration of prostaglandin E ₂ or oral misoprostol. The advantage of using a balloon catheter is that it avoids uterine hyperstimulation and monitoring is less expensive. This makes balloon catheters a suitable option for outpatient cervical ripening. Admittedly, intravenous administration of oxytocin to induce or augment labor is required in approximately 75% of cases. Balloon catheters are not associated with a higher risk of maternal and neonatal infection compared to vaginal PGE ₂ . Low-risk pregnancies (e.g., post-term pregnancies, gestational diabetes) are suitable for outpatient cervical ripening with a balloon catheter. The data for high-risk pregnancies are still insufficient. The following conditions are recommended when considering an outpatient approach: strict selection of appropriate patients (singleton pregnancy, cephalic presentation, intact membranes), CTG monitoring for 20 – 40 minutes after balloon placement, the patient must be given detailed instructions about the indications for immediate readmission to hospital, and 24-hour phone access to the hospital must be ensured. According to reviewed studies, the balloon catheter remained in place between 12 hours (“overnight”) and 24 hours. The most common reason for readmission to hospital was expulsion of the balloon catheter. The advantages of outpatient versus inpatient induction of cervical ripening with a balloon catheter were the significantly shorter hospital stay, the lower costs, and higher patient satisfaction, with both procedures having been shown to be equally effective. Complication rates (e.g., vaginal bleeding, severe pain, uterine hyperstimulation syndrome) during the cervical ripening phase are low (0.3 – 1.5%); severe adverse outcomes (e.g., placental abruption) have not been reported. Compared to inpatient induction of labor using vaginal PGE ₂ , outpatient cervical ripening using a balloon catheter had a lower rate of deliveries/24 hours and a significantly higher need for oxytocin; however, hospital stay was significantly shorter, frequency of pain during the cervical ripening phase was significantly lower, and patientsʼ duration of sleep was longer. A randomized controlled study comparing outpatient cervical priming with a balloon catheter with outpatient or inpatient induction of labor with oral misoprostol would be of clinical interest.

Home versus inpatient induction of labour for improving birth outcomes

BACKGROUND

The setting in which induction of labour takes place (home or inpatient) is likely to have implications for safety, women's experiences and costs. Home induction may be started at home with the subsequent active phase of labour happening either at home or in a healthcare facility (hospital, birth centre, midwifery-led unit). More commonly, home induction starts in a healthcare facility, then the woman goes home to await the start of labour. Inpatient induction takes place in a healthcare facility where the woman stays while awaiting the start of labour.

OBJECTIVES

To assess the effects on neonatal and maternal outcomes of third trimester home induction of labour compared with inpatient induction using the same method of induction.

SEARCH METHODS

For this update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (31 January 2020)), and reference lists of retrieved studies.

SELECTION CRITERIA

Published and unpublished randomised controlled trials (RCTs) in which home and inpatient settings for induction have been compared. We included conference abstracts but excluded quasi-randomised trials and cross-over studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study reports for inclusion. Two review authors carried out data extraction and assessment of risk of bias independently. GRADE assessments were checked by a third review author.

MAIN RESULTS

We included seven RCTs, six of which provided data on 1610 women and their babies. Studies were undertaken between 1998 and 2015, and all were in high- or upper-middle income countries. Most women were induced for post dates. Three studies reported government funding, one reported no funding and three did not report on their funding source. Most GRADE assessments gave very low-certainty evidence, downgrading mostly for high risk of bias and serious imprecision. 1. Home compared to inpatient induction with vaginal prostaglandin E (PGE) (two RCTs, 1028 women and babies; 1022 providing data). Although women's satisfaction may be slightly better in home settings, the evidence is very uncertain (mean difference (MD) 0.16, 95% confidence interval (CI) -0.02 to 0.34, 1 study, 399 women), very low-certainty evidence. There may be little or no difference between home and inpatient induction for other primary outcomes, with all evidence being very low certainty: - spontaneous vaginal birth (average risk ratio (RR) [aRR] 0.91, 95% CI 0.69 to 1.21, 2 studies, 1022 women, random-effects method); - uterine hyperstimulation (RR 1.19, 95% CI 0.40 to 3.50, 1 study, 821 women); - caesarean birth (RR 1.01, 95% CI 0.81 to 1.28, 2 studies, 1022 women); - neonatal infection (RR 1.29, 95% CI 0.59 to 2.82, 1 study, 821 babies); - admission to neonatal intensive care unit (NICU) (RR 1.20, 95% CI 0.50 to 2.90, 2 studies, 1022 babies). Studies did not report serious neonatal morbidity or mortality. 2. Home compared to inpatient induction with controlled release PGE (one RCT, 299 women and babies providing data). There was no information on whether the questionnaire on women's satisfaction with care used a validated instrument, but the findings presented showed no overall difference in scores. We found little or no difference between the groups for other primary outcomes, all also being very low-certainty evidence: - spontaneous vaginal birth (RR 0.94, 95% CI 0.77 to 1.14, 1 study, 299 women); - uterine hyperstimulation (RR 1.01, 95% CI 0.51 to 1.98, 1 study, 299 women); - caesarean births (RR 0.95, 95% CI 0.64 to 1.42, 1 study, 299 women); - admission to NICU (RR 1.38, 0.57 to 3.34, 1 study, 299 babies). The study did not report on neonatal infection nor serious neonatal morbidity or mortality. 3. Home compared to inpatient induction with balloon or Foley catheter (four RCTs; three studies, 289 women and babies providing data). It was again unclear whether questionnaires reporting women's experiences/satisfaction with care were validated instruments, with one study (48 women, 69% response rate) finding women were similarly satisfied. Home inductions may reduce the number of caesarean births, but the data are also compatible with a slight increase and are of very low-certainty (RR 0.64, 95% CI 0.41 to 1.01, 2 studies, 159 women). There was little or no difference between the groups for other primary outcomes with all being very low-certainty evidence: - spontaneous vaginal birth (RR 1.04, 95% CI 0.54 to 1.98, 1 study, 48 women): - uterine hyperstimulation (RR 0.45, 95% CI 0.03 to 6.79, 1 study, 48 women); - admission to NICU (RR 0.37, 95% CI 0.07 to 1.86, 2 studies, 159 babies). There were no serious neonatal infections nor serious neonatal morbidity or mortality in the one study (involving 48 babies) assessing these outcomes.

AUTHORS' CONCLUSIONS

Data on the effectiveness, safety and women's experiences of home versus inpatient induction of labour are limited and of very low-certainty. Given that serious adverse events are likely to be extremely rare, the safety data are more likely to come from very large observational cohort studies rather than relatively small RCTs.

Outpatient management of pre-induction cervical ripening

INTRODUCTION

Induction of labor is a common obstetric intervention. For women requiring cervical ripening, the current standard practice of inpatient labor induction can be long and challenging. Outpatient cervical ripening may be a safe and beneficial option for a select subset of low-risk pregnant women.

METHODS

Electronic databases were searched with specific criteria to select articles for review. The review covered literature on the safety, efficacy and acceptability of outpatient cervical ripening in the low-risk population.

DISCUSSION

Pharmacological and mechanical cervical ripening agents have been trialed in the outpatient setting. Mechanical ripening is safer than pharmacological priming, and there appears to be no disadvantage to offering outpatient catheter balloon cervical ripening to appropriately screened women who require this intervention prior to labor induction. Maternal and midwifery acceptability of outpatient care further support outpatient cervical ripening for women with low-risk pregnancies.

CONCLUSION

The balloon catheter appears to be the optimal method for outpatient cervical ripening, but further prospective studies are required to ensure safety and benefit before it can be routinely offered to low-risk women.

Inpatient versus outpatient induction of labour: a systematic review and meta-analysis

Background

As the number of indications for labour induction continue to increase, the focus has shifted to performing these procedures in an outpatient setting. This study aims to systematically review published data from randomized controlled trials that compare outpatient with inpatient labour induction, to ascertain the role of outpatient labour induction for low-risk pregnancies.

Methods

We conducted a systematic review wherein we searched MEDLINE, EMBASE, Biosis Previews®, and International Pharmaceutical Abstracts from inception to January 2020 to identify randomized controlled trials that reported on maternal, fetal and resource-related outcomes following outpatient versus inpatient labour induction. Pooled incidences and mean differences were calculated using random-effects meta-analysis. Risk-of-bias was assessed using the Cochrane Risk of Bias tool. Subgroup analysis was conducted based on the method of induction.

Results

Of the 588 records identified, 12 publications, representing nine independent randomized controlled trials conducted in Australia, Europe and North America, were included. These reported on 2615 cases of labour induction (1320 outpatients versus 1295 inpatients). Overall, apart from a higher number of suspicious fetal heart rate tracings [RR = 1.43 (1.10, 1.86)] and a shorter mean length of hospital stay [MD = 282.48 min (160.23, 404.73) shorter] in the outpatient group, there were no differences in delivery method, adverse outcomes or resource-use between the two arms. On subgroup analysis, when comparing the use of balloon catheters in both arms, those induced as outpatients had fewer caesarean deliveries [RR = 0.52 (0.30, 0.90)], a shorter admission-to-delivery interval [MD = 370.86 min (19.19, 722.54) shorter], and a shorter induction to delivery interval [MD = 330.42 min (120.13, 540.71) shorter].

Conclusion

Outpatient labour induction in resource-rich settings is at least as effective and safe, in carefully selected patient populations, when compared with inpatient labour induction. Whether outpatient labour induction results in lower rates of caesarean deliveries needs to be explored further.

Trial registration

This systematic review was prospectively registered in Prospero (CRD42019118049).