A randomised controlled trial of intravaginal dinoprostone, intravaginal misoprostol and transcervical balloon catheter for labour induction

[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Trials comparing these two methods, published or unpublished up to July 2023, in French or English were searched for in the PubMed, Cochrane Library and ClinicalTrial.govs datasets.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.

Vaginal misoprostol versus vaginal dinoprostone for cervical ripening and induction of labour: An individual participant data meta-analysis of randomised controlled trials

BACKGROUND

Induction of labour (IOL) is common practice and different methods carry different effectiveness and safety profiles.

OBJECTIVES

To compare the effectiveness, and maternal and perinatal safety outcomes of IOL with vaginal misoprostol versus vaginal dinoprostone using individual participant data from randomised clinical trials.

SEARCH STRATEGY

The following databases were searched from inception to March 2023: CINAHL Plus, ClinicalTrials.gov, Cochrane Pregnancy and Childbirth Group Trial Register, Ovid Embase, Ovid Emcare, Ovid MEDLINE, Scopus and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

Randomised controlled trials (RCTs), with viable singleton gestation, no language restrictions, and all published and unpublished data.

DATA COLLECTION AND ANALYSIS

An individual participant data meta-analysis was carried out.

MAIN RESULTS

Ten of 52 eligible trials provided individual participant data, of which two were excluded after checking data integrity. The remaining eight trials compared low-dose vaginal misoprostol versus dinoprostone, including 4180 women undergoing IOL, which represents 32.8% of all participants in the published RCTs. Of these, 2077 were assigned to low-dose vaginal misoprostol and 2103 were assigned to vaginal dinoprostone. Compared with vaginal dinoprostone, low-dose vaginal misoprostol had a comparable rate of vaginal birth. Composite adverse perinatal outcomes did not differ between the groups. Compared with vaginal dinoprostone, composite adverse maternal outcomes were significantly lower with low-dose vaginal misoprostol (aOR 0.80, 95% CI 0.65-0.98, P = 0.03, I2  = 0%).

CONCLUSIONS

Low-dose vaginal misoprostol and vaginal dinoprostone for IOL are comparable in terms of effectiveness and perinatal safety. However, low-dose vaginal misoprostol is likely to lead to a lower rate of composite adverse maternal outcomes than vaginal dinoprostone.

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.

The association between maternal colonization with Group B Streptococcus and infectious morbidity following transcervical Foley catheter-assisted labor induction

OBJECTIVES

To determine whether maternal colonization with Group B Streptococcus increases the risk for infectious morbidity following transcervical Foley catheter-assisted cervical ripening.

METHODS

A retrospective cohort study comparing infectious morbidity and other clinical outcomes by Group B Streptococcus colonization status between all women with singleton pregnancies who underwent Foley catheter-assisted cervical ripening labor induction at a single tertiary medical center during 2011-2021. Multivariable logistic regression explored the relationship between Group B Streptococcus colonization to adverse outcomes while adjusting for relevant clinical variables.

RESULTS

A total of 4,409 women were included of whom 886 (20.1 %) were considered Group B Streptococcus carriers and 3,523 (79.9 %) were not. Suspected neonatal sepsis rate was similar between Group B Streptococcus carriers and non-carriers (5.2 vs. 5.0 %, respectively, p=0.78). Neonatal sepsis was confirmed in 7 (0.02 %) cases, all born to non-carriers. Group B Streptococcus carriers had a higher rate of maternal bacteremia compared to non-carriers (1.2 vs. 0.5 %, respectively, p=0.01). Group B Streptococcus colonization was independently associated with maternal bacteremia (adjusted odds ratio 3.05; 95 %CI 1.39, 6.66).

CONCLUSIONS

Group B Streptococcus colonization among women undergoing Foley catheter-assisted cervical ripening does not seem to increase the risk for neonatal infection. However, higher rates of maternal bacteremia were detected.

Mechanical methods for induction of labour

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Evaluation of mechanical and nonmechanical methods of cervix ripening in women with premature rupture of membranes: a randomized controlled trial

BACKGROUND

Premature rupture of membranes occurs in 8% of pregnancies. In the absence of spontaneous labor, induction of labor is considered an appropriate strategy for term pregnant women with premature rupture of membranes. There are several approaches for preinduction cervical ripening, including mechanical methods, such as Foley catheterization, and nonmechanical methods, such as oral misoprostol.

OBJECTIVE

This study aimed to evaluate and compare the effects of oral misoprostol and Foley catheterization in pregnant women with premature rupture of membranes at ≥34 weeks of gestation who underwent induction of labor.

STUDY DESIGN

A randomized clinical trial was conducted. The inclusion criteria included nulliparous and multiparous pregnant women at ≥34 weeks of gestation with singleton pregnancies, cephalic presentation, and confirmed amniotic fluid leakage for more than 60 minutes. A total of 104 participants were randomly allocated into 2 groups, one receiving sublingual misoprostol and the other receiving transcervical Foley catheter for cervical ripening. The primary outcome was time from intervention to delivery, and the secondary outcomes included delivery method, maternal and neonatal results (chorioamnionitis, Apgar score, neonatal sepsis, and asphyxia), and arterial blood gas analysis of the umbilical cord.

RESULTS

The mean time from induction of labor to delivery (11.6±1.98 hours for Foley catheter vs 10.16±2.35 hours for misoprostol; P=.007) and the median duration of cervical ripening (4.5 hours [interquartile range, 0.0-6.0] for Foley catheter vs 4.0 hours [interquartile range, 1.5-6.0] for misoprostol; P=.04) were longer in the Foley catheter group than in the misoprostol group. There was no statistically significant difference in the cesarean delivery rate between the 2 groups (29.6% for Foley catheter vs 38.5% for misoprostol; P=.2). There was no case of chorioamnionitis or asphyxia in the 2 groups. There was no significant difference between the 2 groups in terms of umbilical cord pH and the 1- and 5-minute Apgar scores (P=.1, P=.4, and P=.1); nevertheless, these values were higher in the Foley catheter group. There was no statistically significant difference among additional secondary outcomes.

CONCLUSION

In premature rupture of membranes cases, cervical ripening with a Foley catheter was associated with a longer duration of ripening and time from induction to delivery than cervical ripening with misoprostol. The cesarean delivery rate and the maternal and neonatal infection rates were not different between these methods.

Labor induction in third trimester non-viable fetus

OBJECTIVE

We aimed to assess the efficacy of three different labor induction methods for non-viable third-trimester fetuses.

METHODS

This retrospective cohort study included women who had an intra-uterine fetal death or termination of pregnancy at or after 28 weeks of gestation and underwent labor induction by either transcervical foley catheter and concomitant oxytocin infusion or regular doses of vaginal Prostin^© or Propess^©.The primary outcome was induction to the delivery interval. Secondary outcomes included the rate of women who delivered within 24 h, time spent in the delivery room, failed induction, adverse outcomes and reported occurrence of moderate to severe pain.

RESULTS

Between January 2017 to June 2020, 107 women met the inclusion criteria. 25 women underwent induction of labor using transcervical foley catheter, 44 using Propess^©, and 58 by Prostin^©. The three groups were found to be demographically similar. The rate of women who delivered within 24 h was higher in the transcervical foley catheter group compared to the Propess^© and Prostin^© groups (72% vs 25% vs 29.3%, p < .001 respectively). Time to delivery was shorter among the transcervical foley catheter group compared to the Propess^© and Prostin^© groups (16.97 h vs 39.4 vs 39.3, p < .001 respectively). When comparing the Foley catheter group to both Propess^© and Prostin^©, moderate to severe pain was significantly more commonly reported in the prostaglandins groups (36.0% vs 50.0% vs 65.62%, p = .04). No difference was found in adverse outcomes, defined as intrapartum fever, post-partum hemorrhage and retained placenta.

CONCLUSION

Cervical foley catheter with concomitant oxytocin infusion is the most effective method for induction of labor in third trimester non-viable in fetus compared to PGE2.

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.

Comparison of intracervical and intravaginal prostaglandin E2 for induction of labor in term pregnancies with unfavorable cervix: Randomized controlled trial

OBJECTIVE

The aim of this study was to compare intracervical (IC) and intravaginal (IV) application of prostaglandin E2 (PGE2) for labor induction in term pregnancies with unfavorable cervix.

STUDY DESIGN

This prospective randomized trial included 212 pregnant women with term pregnancy and unfavorable cervix randomly assigned for labor induction with either IC (0.5 mg) or IV (2 mg) PGE2 formulation. Main outcome measured was time interval from labor induction to delivery. Difference in mode of delivery and adverse perinatal outcomes between two studied groups was also investigated. Significance was set at p < 0.05.

RESULTS

Studied groups did not significantly differ regarding main characteristics such as age, parity, body mass index or Bishop score. Women in IV group compared to those in IC group had shorter induction to delivery time interval (p < 0.001) and induction to active phase time interval (p = 0.001), higher prevalence of vaginal delivery within 24 h of labor induction (63,3% vs 40,6%, p = 0.002) and higher prevalence of successful induction of labor (95,9% vs. 86,5%, p = 0.020). The analysis did not reveal significant difference in mode of delivery between groups (p = 0.453) or other adverse perinatal outcomes.

CONCLUSION

IV application of PGE2 compared to IC application is more efficacious and comparably safe for labor induction in term pregnancies with unfavorable cervix and should be the method of choice for labor induction.

Efficacy and safety of oral misoprostol vs transvaginal balloon catheter for labor induction: An observational study within the SWEdish Postterm Induction Study (SWEPIS)

INTRODUCTION

Induction of labor is increasing. A common indication for induction of labor is late term and postterm pregnancy at 41 weeks or more. We aimed to evaluate if there are any differences regarding efficacy, safety, and women's childbirth experience between oral misoprostol and transvaginal balloon catheter for cervical ripening in women with a low-risk singleton pregnancy and induction of labor at 41⁺⁰ to 42^{+0 to 1} weeks of gestation.

MATERIAL AND METHODS

In this observational study, based on data from the Swedish Postterm Induction Study (SWEPIS), a multicenter randomized controlled trial, a total of 1213 women with a low-risk singleton pregnancy at 41 to 42 weeks of gestation were induced with oral misoprostol (n = 744) or transvaginal balloon catheter (n = 469) at 15 Swedish delivery hospitals. The primary efficacy outcome was vaginal delivery within 24 h and primary safety outcomes were neonatal and maternal composite adverse outcomes. Secondary outcomes included time to vaginal delivery and mode of delivery. Women's childbirth experience was assessed with the Childbirth Experience Questionnaire (CEQ 2.0) and visual analog scale. We present crude and adjusted mean differences and relative risks (RR) with 95% CI. Adjustment was performed for a propensity score based on delivery hospital and baseline characteristics including Bishop score.

RESULTS

Vaginal delivery within 24 h was significantly lower in the misoprostol group compared with the balloon catheter group (46.5% [346/744] vs 62.7% [294/469]; adjusted RR 0.76 95% CI 0.640.89]). Primary neonatal and maternal safety outcomes did not differ between groups (neonatal composite 3.5% [36/744] vs 3.2% [15/469]; adjusted RR 0.77 [95% CI 0.31-1.89]; maternal composite 2.3% [17/744] vs 1.9% [9/469]; adjusted RR 1.70 [95% CI 0.58-4.97]). Adjusted mean time to vaginal delivery was increased by 3.8 h (95% CI 1.3-6.2 h) in the misoprostol group. Non-operative vaginal delivery and cesarean delivery rates did not differ. Women's childbirth experience was positive overall and similar in both groups.

CONCLUSIONS

Induction of labor with oral misoprostol compared with a transvaginal balloon catheter was associated with a lower probability of vaginal delivery within 24 h and a longer time to vaginal delivery. However, primary safety outcomes, non-operative vaginal delivery, and women's childbirth experience were similar in both groups. Therefore, both methods can be recommended in women with low-risk postdate pregnancies.

Induction of labor using Foley catheter with weight attached versus without weight attached: A randomized control trial

OBJECTIVE

To assess the effectiveness in preventing cesarean section for failed induction by using Foley catheter for cervical ripening in comparison to Foley catheter with a weight attached to it.

METHODS

A randomized control trial conducted between November 2018 and July 2020, which looked at induction of labor with 30-ml Foley catheter in one arm and the Foley placed with a 500 ml weight attached to it in the other arm. Primary outcome was the cesarean section rate.

RESULTS

We randomized 399 women. Modes of delivery were similar in both groups. Numbers undergoing cesarean section for failed induction were higher in the group that underwent induction with Foley with weight but this was not statistically significant (45.7% vs 26.5%, P = 0.1). There was a shorter time to expulsion of the Foley with weight attached (mean ± standard deviation: 2.6 ± 3.3 h vs 10.9 ± 3.2 h, P < 0.001) but this did not translate into a difference in time to active labor or time to delivery.

CONCLUSION

Placing a weight at the end of the Foley catheter for induction of labor does not affect the time to delivery or the rate of cesarean deliveries, although there is faster expulsion of the Foley. Clinical trial registration no.: CTRI/2018/10/016154.

Intracervical double-balloon catheter versus dinoprostone for cervical ripening in labor induction in pregnancies with a high risk of uterine hyperstimulation

PURPOSE

There are numerous methods for cervical ripening although not all of them are indicated in women presenting a higher risk of uterine hyperstimulation. To compare the efficacy and security of the two methods for cervical ripening in the induction of labor in these pregnancies.

METHODS

Retrospective analysis of two cohorts consisting of pregnant women who gave birth from 2016 to 2019 (112 inductions with dinoprostone and 112 with intracervical double- balloon).

RESULTS

There are statistically significant differences in favor of dinoprostone in deliveries that occurred before 12 h since the start of the induction (28.6% vs 13.4%, p = 0.005) and a higher rate of cervical ripening (55.4% vs 33.9%; p = 0.001). There were no statistically significant differences in induction time, the percentage of women delivering within 24 h or beyond, nor in the type of delivery. Additionally, a decreased need of oxytocin (60.7% vs 42.9%; p = 0.001) and a lower dose when used has been observed in the dinoprostone group. However, Dinoprostone also has a higher rate of minor maternal complications as uterine hyperstimulation (18.8% vs 3.6%; p = 0.001) and altered cardiotocography (26.8% vs 4.5%; p = 0.001). No significant difference has been found between the two groups regarding severe complications.

CONCLUSIONS

Dinoprostone presents a greater efficacy for cervical ripening and delivery in ≤ 12 h, with less need of oxytocin perfusion than inductions using an intracervical double-balloon. There is no significant difference in severe maternal complications between the two groups. In conclusion, Dinoprostone could be an effective and safe option for patients at risk of uterine hyperstimulation.

Efficacy and safety of controlled-release dinoprostone vaginal delivery system (PROPESS) in Japanese pregnant women requiring cervical ripening: Results from a multicenter, randomized, double-blind, placebo-controlled phase III study

AIM

To evaluate the efficacy and safety of dinoprostone vaginal insert (PROPESS) in pregnant post-term Japanese women requiring cervical ripening.

METHODS

This randomized, double-blind, placebo-controlled study included 114 pregnant Japanese women at term (41 weeks of gestation) requiring cervical ripening (baseline Bishop score (BS) ≤ 4). The primary end-point was the proportion of subjects with successful cervical ripening defined as BS ≥ 7 or vaginal delivery in 12 h. The secondary end-points were changes in BS, proportion of women with vaginal delivery, proportion of women receiving mechanical cervical ripening procedure and use of oxytocic drugs.

RESULTS

PROPESS administration for a maximum of 12 h showed significantly higher successful cervical ripening rate (47.4% vs 14.3%, respectively; treatment contrast [TC]: 33.1%; P = 0.0002). The median time from administration to vaginal delivery was significantly shorter in the PROPESS group than in the placebo group (26.18 h vs 33.02 h; OR 2.51; 95% CI [1.60-3.92]; P < 0.0001). In the PROPESS group, the dosage of uterotonic drugs, such as oxytocin, decreased, and the number of patients who used these drugs also decreased.

CONCLUSION

PROPESS administration for a maximum of 12 h was an effective and well-tolerated treatment for pregnant Japanese women post-term requiring cervical ripening.

Term prelabor rupture of membranes: Foley catheter versus dinoprostone as ripening agent

INTRODUCTION

Term prelabor rupture of membranes (TPROM) occurs in approximately 8 % of pregnancies. This condition regularly requires medical intervention such as induction of labor. The actual data concerning cervical ripening in case of TPROM does not favor any of the available techniques. This is the first study comparing dinoprostone versus Foley catheter for cervical ripening in TPROM.

MATERIALS AND METHODS

We conducted a retrospective before-after study. We enrolled all the patients with confirmed TPROM after 37 weeks of gestation (WG) who required cervical ripening. Women were included if they had a singleton fetus in cephalic presentation, with unfavorable cervix (Bishop ≤ 6). Patients were excluded if they had a previous uterine surgery, a multiple pregnancy, contraindication to vaginal delivery, spontaneous labor or favorable cervix (Bishop > 6). During the first period (2015), the protocol of cervical ripening involved dinoprostone (prostaglandins E2) by vaginal administration (vaginal gel or pessary). During the second period (2016-2017), the protocol of cervical ripening involved Foley catheter (FC). The primary outcome was the rate of cesarean section.

RESULTS

Two hundred and thirty-eight patients were included for the analysis: 131 in the first period (dinoprostone group) and 107 in the second period (foley catheter group). There was no significant difference between the two groups regarding the mode of delivery (cesarean section: 206 % vs 13 %, p = 016). Concerning tolerance, the were no difference in the rates of postpartum hemorrhage, maternal per-partum fever and endometrisis. Neonatal outcomes were similar between the two groups. The induction to delivery interval was lower with dinoprostone (20,3 h versus 26,0 h, p = 0001). The mean duration of labor was also significantly different (6,9 h for dinoprostone group versus 8,7 h for FC group, p = 001).

CONCLUSION

Cervical ripening in case of TPROM after 37 W G with Foley catheter seems to be a safe technique with similar outcomes to prostaglandins regarding the mode of delivery.

Balloon catheter use for cervical ripening in women with term pre-labor rupture of membranes: A 5-year cohort study

INTRODUCTION

To investigate the safety of balloon catheter for cervical ripening in women with term pre-labor rupture of membranes (PROM) and to compare the incidence of maternal and neonatal infections in women with PROM and women with intact membranes undergoing cervical ripening with a balloon catheter.

MATERIAL AND METHODS

This retrospective cohort study of 1923 women with term singleton pregnancy and an unfavorable cervix undergoing cervical ripening with a balloon catheter was conducted in Helsinki University Hospital between January 2014 and December 2018. For each case of PROM, two controls were assigned. The main outcome measures were the rates of maternal and neonatal infections. Statistical analyses were performed by SPSS.

RESULTS

In all, 641 (33.3%) women following PROM and 1282 (66.6%) women with intact amniotic membranes underwent labor induction. The rates of intrapartum infection (3.7% vs 7.7%; P = .001) and neonatal infection (1.7% vs 3.8%; P = .01) were not increased in women induced by balloon catheter following PROM. Intrapartum infections were associated with nulliparity (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.6-6.5), history of previous cesarean section (OR 2.8, 95% CI 1.2-6.4), extended gestational age ≥41 weeks (OR 1.9, 95% CI 1.2-3.0) and an induction to delivery interval of 48 hours or more (OR 2.0, 95% CI 1.2-3.3). The risk of neonatal infection was associated with nulliparity (OR 3.3, 95% CI 1.4-8.0), gestational age ≥41 weeks (OR 1.9, 95% CI 1.09-3.36) and induction to delivery interval of 48 hours or more (OR 3.4, 95% CI 1.9-6.0).

CONCLUSIONS

Use of balloon catheter in women with term PROM appears safe and was not associated with increased maternal or neonatal infectious morbidity.

Oral Misoprostol Versus Vaginal Prostaglandin E2 Labor Induction Efficiency, Safety, and Labor Outcomes

BACKGROUND

Prostaglandin E1 (oral misoprostol) and the other Prostaglandin E2 (Dinoprostone gel) are promising agents for cervical ripening and induction of labor.

AIMS OF STUDY

To compare the efficiency and safety on maternal-fetal outcomes using 25 micrograms oral misoprostol PGE1 with 50 micrograms of intra-vaginal PGE2 for induction of labor.

METHODS

This was a retrospective study design reviewing medical records of induced labor at Al Shifa hospital in Gaza Strip.

RESULTS

In general, the results showed that women who used oral misoprostol with an age less than 30 years and parity less than 3 was effective for delivery and safe outcomes with an odds ratio (OR) of 15.8 (CI 6.9–39.8) and OR 29.2 (CI 10.7–80.3) respectively. The most common indication for labor induction in both methods was reputure of the membrane (ROM) more than 24 hours, postdates, and a medical disorder. However, the total interval hours for both methods was 8.4 hours. The mode of delivery was similar in both groups as vaginal delivery outcome was 73.6% for oral misoprostol E1 and 75% for prostaglandin E2 cases. However, PGE2 induction showed a higher cesarean delivery 25% rate versus 18.4%. Clinically the use of oral misoprostol showed a higher percentage of birth canal injury, failed induction, uterine rupture by 9.3%, 8%, 1.3% respectively. Fetal distress was found as the most common fetal complication and the most common cause for cesarean section.

CONCLUSION

The study recommended more research is needed as present evidence does not support use of oral misoprostol versus Prostaglandin E2.

MEchanical DIlatation of the Cervix-- in a Scarred uterus (MEDICS): the study protocol of a randomised controlled trial comparing a single cervical catheter balloon and prostaglandin PGE2 for cervical ripening and labour induction following caesarean delivery

INTRODUCTION

Labour induction in women with a previous caesarean delivery currently uses vaginal prostaglandin E2 (PGE2), which carries the risks of uterine hyperstimulation and scar rupture. We aim to compare the efficacy of mechanical labour induction using a transcervically applied Foley catheter balloon (FCB) with PGE2 in affected women attempting trial of labour after caesarean (TOLAC).

METHODS AND ANALYSIS

This single-centre non-inferiority prospective, randomised, open, blinded-endpoint study conducted at an academic maternity unit in Singapore will recruit a total of 100 women with one previous uncomplicated caesarean section and no contraindications to vaginal delivery. Eligible consented participants with term singleton pregnancies and unfavourable cervical scores (≤5) requiring labour induction undergo stratified randomisation based on parity and are assigned either FCB (n=50) or PGE2 (n=50). Treatments are applied for up to 12 hours with serial monitoring of the mother and the fetus and serial assessment for improved cervical scores. If the cervix is still unfavourable, participants are allowed a further 12 hours' observation for cervical ripening. Active labour is initiated by amniotomy at cervical scores of ≥6. The primary outcome is the rate of change in the cervical score, and secondary outcomes include active labour within 24 hours of induction, vaginal delivery, time-to-delivery interval and uterine hyperstimulation. All analyses will be intention-to-treat. The data generated in this trial may guide a change in practice towards mechanical labour induction if this proves efficient and safer for women attempting TOLAC compared with PGE2, to improve labour management in this high-risk population.

ETHICS AND DISSEMINATION

Ethical approval is granted by the Domain Specific Review Board (Domain D) of the National Healthcare Group, Singapore. All adverse events will be reported within 24 hours of notification for assessment of causality. Data will be published and will be available for future meta-analyses.

TRIAL REGISTRATION NUMBER

NCT03471858; Pre-results.

Mechanical methods for induction of labour

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Sublingual Misoprostol versus Foley catheter for cervical ripening in women with preeclampsia or gestational hypertension: A randomized control trial

Background

Delivery is the only definite cure for hypertensive disorders. Therefore, cervical ripening and labor induction are important to achieve favorable outcomes.

Objective

This Randomized Control Trial (RCT) is aimed to compare the effects of sublingual misoprostol and Foley catheter in cervical ripening and labor induction among patients with preeclampsia or gestational hypertension.

Materials and Methods

A total number of 144 women with preeclampsia or gestational hypertention with indication of pregnancy termination, who were referred to academic hospitals of the University of Medical Sciences in Mashhad, Iran, between March 2015 and December 2016, were randomly divided into two groups. In group one (n = 72), 25 µg of misoprostol tablet was administrated sublingually every 4 hr up to six doses. In group two (n = 72), a 16F Foley catheter was placed through the internal cervical os, inflated with 60 cc of sterile saline.

Results

There were no significant differences between groups regarding the demographic characteristics, primary bishop score, and pregnancy termination indication. The cervical ripening time (primary outcome) (8.2 vs 14.2 hr, p < 0.00), induction to delivery interval (15.5 vs 19.9 hr, p < 0.00), and vaginal delivery before 24 hr (63.9% vs 40%, p = 0.03) were significantly different between the two groups. There was no significant difference between groups in view of oxytocin requirement (p = 0.12), neonatal Apgar score (p = 0.84), or neonatal intensive care unit admission (p = 78).

Conclusion

This trial showed that the application of sublingual misoprostol, compared to the Foley catheter, can reduce cervical ripening period and other parameters related to the duration of vaginal delivery. This misoprostol regimen showed inconsiderable maternal complications.

A comparison of cervical ripening modalities among overweight and obese nulliparous gravidas

Objective: To determine if differences exist among nulliparous overweight and obese gravidas undergoing cervical ripening employing three different agents (dinoprostone, misoprostol, or cervical catheter).Methods: A retrospective cohort study of nulliparous overweight and obese women who underwent induction of labor at two south-central Pennsylvania hospitals between January 2014 and December 2017. Nulliparous gravidas, ≥37 weeks' gestational age, with singleton pregnancies in the vertex presentation, were included in the study. We employed the following definitions: (1) overweight: BMI 25.0-29.9 kg/m²; (2) class I obesity: BMI 30.0-34.9 kg/m²; (3) class II obesity: BMI 35.0-39.9 kg/m²; and (4) class III obesity: BMI >40.0 kg/m². The primary outcome measure was the mean difference in induction-to-birth time. A subanalysis was performed to assess the effect of BMI on the primary outcome. Secondary outcome measures included mode of delivery, induction-to-second-stage-of-labor time, estimated blood loss, neonatal feeding type, neonatal Apgar scores, and neonatal admission to triage or intensive care unit (ICU) after delivery. A priori power calculation estimated that 156 patients would be needed using the medium effective size. Data analysis was performed using ANOVA for continuous variables and chi-square tests for categorical variables.Results: Among 192 nulliparous overweight and obese gravidas, 70 received dinoprostone, 72 were given misoprostol, and 50 had cervical ripening with cervical catheters. There were no significant differences in mean induction to birth times among overweight and obese women when comparing the three cervical ripening agents (dinoprostone 24.5 ± 15.2 versus misoprostol 28.7 ± 12.3 and catheters 25.1 ± 12.9 hours), (p = .145, 95% CI -8.7 to 0.2 and -5.5 to 4.3, respectively). Overweight nulliparous women had shorter mean induction to birth time (22.9 ± 11.4 versus 29.2 ± 15.8 hours) as compared to class II obese women, (p = .037, 95% CI -12.0 to -0.38). When overweight women were compared to class III obese women, shorter mean induction to birth time (22.9 ± 11.4 versus 30.9 ± 13.9 hours) was also found, (p = .005, 95% CI -13.4 to -2.4).Conclusion: Among nulliparous overweight and obese gravidas, neither dinoprostone, misoprostol, or cervical catheter significantly impacted the induction to birth time. There was a longer induction to birth time for class II and class III obese women when compared to overweight women. Additional studies are warranted to improve cervical ripening in nulliparous overweight and obese women.

Low-dose vaginal misoprostol vs vaginal dinoprostone insert for induction of labor beyond 41st week: A randomized trial

INTRODUCTION

The aim of this study was to compare the efficacy and safety of a low-dose protocol of vaginal misoprostol and vaginal dinoprostone insert for induction of labor in women with post-term pregnancies.

MATERIAL AND METHODS

We designed a prospective, randomized, open-labeled trial with evaluators blinded to the end-point, including women of at least 41 weeks of gestational age with uncomplicated singleton pregnancies and a Bishop score <6. They were randomized into dinoprostone or misoprostol groups in a 1:1 ratio. Baseline maternal data and perinatal outcomes were recorded for statistical analysis. Successful vaginal delivery within 24 hours was the primary outcome variable. A P value <0.05 was considered statistically significant. This study was registered in ClinicalTrials.gov (number NTC03744364).

RESULTS

We included 198 women for analysis (99 women in each group). Vaginal birth rate within 24 hours did not differ between groups (49.5% vs 42.4%; P = 0.412). When the Bishop score was <4, dinoprostone insert showed a higher probability of vaginal delivery within 12 hours (17.8% vs 4%; P = 0.012). In the dinoprostone group, removal of the insert was more likely to be due to an adverse event (5.1% vs 14.1%; P = 0.051) and an abnormal fetal heart rate pattern during active labor (44.4% vs 58.6%; P = 0.047). Both groups were similar in neonatal outcomes including Apgar score, umbilical cord pH and neonatal intensive care unit admission.

CONCLUSIONS

Low-dose vaginal misoprostol and vaginal dinoprostone insert seem to be equally effective and safe for induction of labor in pregnant women with a gestational age beyond 41 weeks.

Challenges and Limitations of Clinical Trials on Labor Induction: A Review of the Literature

Induction of labor is a common obstetric procedure performed in nearly a quarter of all deliveries in the United States. Pharmacological (prostaglandins, oxytocin) and/or mechanical methods (balloon catheters) are commonly used for labor induction; however, there is ongoing debate as to which method is the safest and most effective. This narrative review discusses key limitations of published trials on labor induction, including the lack of well-designed randomized controlled trials directly comparing specific methods of induction, heterogeneous trial populations, and wide variation in the protocols used and outcomes reported. Furthermore, the majority of published trials were underpowered to detect significant differences in the most clinically relevant efficacy and safety outcomes (e.g., cesarean delivery, neonatal mortality). By identifying the limitations of labor induction trials, we hope to highlight the importance of quality published data to better inform guidelines and drive evidence-based treatment decisions.

Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour.

OBJECTIVE

To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups.

METHODS

We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group's Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012-13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves.

RESULTS

We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 µg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed 'best'. Few studies collected information on women's views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective.

LIMITATIONS

There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses.

CONCLUSIONS

Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention.

FUTURE WORK

Future trials should be powered to detect a method that is more cost-effective than misoprostol solution and report outcomes included in this NMA.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005116.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Time-to-delivery and delivery outcomes comparing three methods of labor induction in 7551 nulliparous women: a population-based cohort study

OBJECTIVE

Determine time-to-delivery and mode-of-delivery in labor induction among women with unripe cervix.

STUDY DESIGN

7551 nulliparous women with singleton deliveries, ⩾37 weeks, Bishop Score ⩽6, induced with dinoprostone, misoprostol or transcervical single balloon catheter. Linear regression analysis was used to estimate mean time-to-delivery with β-estimates and 95% confidence intervals with adjustments. Multivariable logistic regression analysis was used to calculate odds of cesarean delivery, instrumental vaginal delivery, maternal and neonatal outcomes.

RESULTS

Adjusted mean time-to-delivery was 6.9 and 1.5 h shorter, respectively, when inducing labor with balloon catheter (mean 18.3 h, β -6.9, 95% confidence intervals; -7.6 to -6.3) or misoprostol (mean 23.7 h, β -1.5, 95% confidence intervals; -2.3 to -0.8) compared with dinoprostone (mean 25.2 h). There were no significant differences in adverse maternal or infant outcomes between induction methods.

CONCLUSIONS

Balloon catheter is the most effective induction method with respect to time-to-delivery in nulliparous women at term compared with prostaglandin methods.

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

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

Labor Induction with Orally Administrated Misoprostol: A Retrospective Cohort Study

Introduction

One great challenge in obstetric care is labor inductions. Misoprostol has advantages in being cheap and stable at room temperature and available in resource-poor settings.

Material and Methods

Retrospective cohort study of 4002 singleton pregnancies with a gestational age ≥34 w at Sodersjukhuset, Stockholm, during 2009-2010 and 2012-2013. Previously used methods of labor induction were compared with misoprostol given as a solution to drink, every second hour. Main outcome is as follows: Cesarean Section (CS) rate, acid-base status in cord blood, Apgar score < 7,5′, active time of labor, and blood loss > 1500 ml (PPH).

Results

The proportion of CS decreased from 26% to 17% when orally given solution of misoprostol was introduced at the clinic (p < 0.001). No significant difference in the frequency of low Apgar score (p = 0.3), low aPh in cord blood (p = 0.1), or PPH (p = 0.4) between the different methods of induction was studied. After adjustment for different risk factor for CS the only method of induction which was associated with CS was dinoproston^⁎⁎ (Propess®) (aor = 2.9 (1.6–5.2)).

Conclusion

Induction of labor with misoprostol, given as an oral solution to drink every second hour, gives a low rate of CS, without affecting maternal or fetal outcome.

Outcome of misoprostol and oxytocin in induction of labour

BACKGROUND

Induction of labour is the process of initiating the labour by artificial means from 24 weeks of gestation. The main aim of this study is to find out the maternal and foetal outcomes after induction of labour with misoprostol and oxytocin beyond 37 weeks of gestation.

METHODS

This was a hospital-based observational study carried out at Paropakar Maternity and Women's Hospital, Nepal. Misoprostol of 25 µg was inserted in posterior fornix of vagina or oxytocin infusion was started from 2.5 units on whom induction was decided. Maternal and foetal/neonatal outcomes were observed. Collected data were analysed using SPSS and MS Excel.

RESULTS

General induction rate was found to be 7.2%. In this study, post-term pregnancy was found to be the most common reason for induction of labour. Analysis of onset of labour led to the finding that mean onset of labour was much rapid in oxytocin (6.6 h) than misoprostol (13.6 h). However, there is similarity in induction-delivery interval in both groups. Overall, the rate of normal delivery and caesarean section was found to be 64.9% and 33.2%, respectively. Similarly, normal delivery within 12 h was seen in 18.4% of the patients given with misoprostol and 43.5% in oxytocin group. Foetal distress was found as the most common reason for caesarean section. The overall occurrence of maternal complication was found to be similar in misoprostol and oxytocin groups, nausea/vomiting being the most common (36.7%) complication followed by fever (24.1%). Besides this, the most common neonatal complication found in overall cases was meconium stained liquor (49.2%).

CONCLUSION

It was found that misoprostol was used most frequently for induction of labour compared to oxytocin. The onset of labour was found to be rapid in oxytocin than misoprostol. However, the occurrence of side effects was found to be similar in both misoprostol and oxytocin groups.

Induction of Labor Using a Foley Catheter or Misoprostol: A Systematic Review and Meta-analysis

Importance

Induction of labor is a widely used obstetric intervention, occurring in one in four pregnancies. When the cervix is unfavorable, still many different induction methods are used.

Objective

We compared Foley catheter alone to different misoprostol dosages and administration routes, and the combination of Foley catheter with misoprostol.

Evidence acquisition

We reviewed the literature on the best induction method regarding their safety and effectiveness, using the outcome measures hyperstimulation, fetal distress, neonatal morbidity and mortality as well as cesarean delivery, vaginal instrumental delivery, and maternal morbidity. We searched Pubmed, Cochrane, and Web of Science from January 1, 1980 to February 12, 2016. Twenty-two randomized controlled trials (RCTs) were included, comparing Foley catheter with or without misoprostol to misoprostol alone (both vaginal and oral) for induction of labor (5,015 women).

Results

Most included studies were underpowered to detect differences in safety outcomes, as the majority are powered for time to delivery or cesarean delivery. Meta-analysis of these studies does not allow assessment of the safety profile of Foley catheter compared to misoprostol (any dose, any administration route) with sufficient power. For the safety outcomes of the total group of Foley catheter versus misoprostol (any dose, any administration route) (17 studies, 4,234 women) we found that Foley catheter results in less hyperstimulation compared to misoprostol (2% versus 4%; risk ratio [RR], 0.54; 95% confidence interval [CI], 0.37-0.79) and fewer cesarean deliveries for nonreassuring fetal heart rate, 5% vs 7%; RR, 0.72; 95% CI, 0.55-0.95; while there were no statistically significant differences in neonatal outcomes. The total number of cesarean deliveries was 26% versus 22% (RR, 1.16; 95% CI, 1.00-1.34). There were fewer vaginal instrumental deliveries with a Foley catheter compared to misoprostol (10% vs 14%; RR, 0.74; 95% CI, 0.60-0.91). Foley catheter with misoprostol compared to misoprostol alone (any dose, any administration route) (7 studies, 1,073 women) resulted in less hyperstimulation than misoprostol alone (17% vs 23%; RR, 0.71; 95% CI, 0.52-0.97). Cesarean deliveries for nonreassuring fetal heart rate were comparable (7% vs 9%; RR, 0.79; 95% CI, 0.51-1.22). Neonatal outcomes were infrequently reported. The total number of cesarean deliveries was 34% versus 34% (RR, 1.01; 95% CI, 0.86-1.19).

Conclusion

In women with an unripe cervix at term, Foley catheter seems to have a better safety profile than misoprostol (any dose, any administration route) for induction of labor. Larger studies are needed to investigate the safety profile of a Foley catheter compared to separate dosing and administration regimens of misoprostol.

Use of Intracervical Foley Catheter for Induction of Labour in Cases of Previous Caesarean Section: Experience of a single tertiary centre in Oman

OBJECTIVES

This study aimed to evaluate rates of success and perinatal complications of labour induction using an intracervical Foley catheter among women with a previous Caesarean delivery at a tertiary centre in Oman.

METHODS

This retrospective cohort study included 68 pregnant women with a history of a previous Caesarean section who were admitted for induction via Foley catheter between January 2011 and December 2013 to the Sultan Qaboos University Hospital, Muscat, Oman. Patient data were collected from electronic and delivery ward records.

RESULTS

Most women were 25-35 years old (76.5%) and 20 women had had one previous vaginal delivery (29.4%). The most common indication for induction of labour was intrauterine growth restriction with oligohydramnios (27.9%). Most women delivered after 40 gestational weeks (48.5%) and there were no neonatal admissions or complications. The majority experienced no complications during the induction period (85.3%), although a few had vaginal bleeding (5.9%), intrapartum fever (4.4%), rupture of the membranes (2.9%) and cord prolapse shortly after insertion of the Foley catheter (1.5%). However, no cases of uterine rupture or scar dehiscence were noted. Overall, the success rate of vaginal birth after a previous Caesarean delivery was 69.1%, with the remaining patients undergoing an emergency Caesarean section (30.9%).

CONCLUSION

The use of a Foley catheter in the induction of labour in women with a previous Caesarean delivery appears a safe option with a good success rate and few maternal and fetal complications.

Birth Outcomes, Intervention Frequency, and the Disappearing Midwife-Potential Hazards of Central Fetal Monitoring: A Single Center Review

INTRODUCTION

Many birth units use central fetal monitoring (CFM) under the assumption that greater surveillance improves perinatal outcomes. The unexpected loss of the CFM system at a tertiary unit provided a unique opportunity to evaluate outcomes and staff attitudes toward CFM.

METHODS

This retrospective cohort study compared patient data from 2,855 electronically monitored women delivering over a 12-month period, where CFM was available for the first 6 months but unavailable for the following 6 months. Primary outcomes relating to neonatal morbidity and secondary outcomes relating to intrapartum interventions were examined. Additionally, birth unit staff members were surveyed about aspects of care related to CFM.

RESULTS

There were no significant differences in perinatal outcomes between the cohorts. While unadjusted analysis suggested a lower spontaneous vaginal birth rate (55.4% vs 60.3%) and a higher cesarean delivery rate (25.1% vs 22.0%, p = 0.026), together with higher epidural (53.0% vs 49.2%, p = 0.04) and fetal blood sampling (11.8% vs 9.4%, p = 0.03) rates in the presence of CFM, these differences were lost when adjusted for prostaglandin ripening. Over half of the staff (56.0% of midwives, 54.0% of obstetricians) reported spending more time with the laboring woman in the period without CFM.

CONCLUSIONS

This single institution's experience indicates that in birth units staffed for one-to-one care in labor, central fetal monitoring does not appear to be associated with either a benefit on perinatal outcomes or an increase in cesarean delivery and other interventions. However, it is associated with a reduction in the time a midwife spends with the laboring woman.

The Renaissance of Transcervical Balloon Catheters for Cervical Ripening and Labour Induction

Due to rising rates of labour induction in industrialised countries, safe and effective methods of induction have once again become a focus of interest and research. Prostaglandins are effective for cervical ripening and induction of uterine contractions. They do, however, cause overstimulation of the uterus in up to 20 % of cases, sometimes causing changes in fetal heart rate. Transcervical balloon catheters provide an alternative to prostaglandins for labour induction and have been used for this purpose for almost 50 years. This induction method has experienced a recent renaissance in clinical practice that is reflected in an annually rising number of publications on its use. Balloon catheters allow gentle ripening of the cervix without causing uterine overstimulation. The two catheters available are the Foley catheter (off-label use) and the double balloon catheter, which is licensed for use in induction of labour. Both are as effective as prostaglandins, and do not increase the risk of infection to mother or child. Catheter induction also requires less monitoring compared to prostaglandins resulting in improved patient satisfaction. Balloon catheters provide a useful and promising option to achieve vaginal delivery despite failed prostaglandin induction. Intravenous oxytocin is nevertheless required in up to 85 % of cases for adequate induction/augmentation of contractions. Balloon catheters, vaginal PGE₂ and misoprostol are equally effective in the context of an unripe/unfavourable cervix, the rate of uterine hyperstimulation being significantly lower, and the need for oxytocin significantly higher for catheters. Balloon catheters are increasingly being used in combination or sequentially with oral/vaginal misoprostol, although there is currently inadequate published data on the subject. International guidelines recommend the use of balloon catheters for labour induction with an unripe cervix (also following previous caesarean section) as an alternative to prostaglandins, particularly when these are not available or are contraindicated.

Management of Foley catheter induction among nulliparous women: a retrospective study

Background

Induction of labour is associated with increased risk for caesarean delivery among nulliparous women. The aims of this study were to evaluate the risk factors for caesarean delivery and to investigate the risk of maternal and neonatal infections in nulliparous women undergoing induction of labour by Foley catheter.

Methods

This clinical retrospective study of 432 nulliparous women with singleton pregnancy and intact amniotic membranes at or beyond 37 gestational weeks scheduled for induction of labour by Foley catheter was conducted over the course of one year, between January 2012 and January 2013, in Helsinki University Hospital. The main outcome measures were caesarean section rate and maternal and neonatal infections. Univariate and multivariate logistic regressions were used to estimate relative risks by odds ratios with 95 % confidence intervals.

Results

The caesarean section rate was 39.1 % (n = 169). In multivariate regression analysis, the factors associated with caesarean section were the need for oxytocin for labour induction [OR 2.9 (95 % CI 1.8-4.5) p < 0.001] and early epidural analgesia [OR 9.9 (95 % CI 2.1-47.5), p = 0.004]. The maternal intrapartum infection rate was 6.3 %, and the clinical neonatal infection rate was 2.8 %. In multivariate analysis, gestational diabetes was associated with maternal intrapartum infection [OR 4.3 (95 % CI 1.7-11.0, p = 0.002] and early epidural analgesia with neonatal clinical sepsis [OR 10.5 (95 % CI 1.4-76), p = 0.02].

Conclusions

Oxytocin induction and early epidural analgesia were associated with caesarean delivery. Gestational diabetes and early epidural analgesia were associated with infectious morbidity. Since the first caesarean delivery has a major impact on subsequent pregnancies, optimising labour induction among nulliparous women is important.

Foley Catheter versus Vaginal Misoprostol for Labour Induction

Objectives. To compare the efficacy and safety of intravaginal misoprostol with transcervical Foley catheter for labour induction. Material and Methods. One hundred and four women with term gestation, with Bishop score < 4, and with various indications for labour induction were randomly divided into two groups. In Group I, 25 μg of misoprostol tablet was placed intravaginally, 4 hourly up to maximum 6 doses. In Group II, Foley catheter 16F was placed through the internal os of the cervix under aseptic condition and then inflated with 50 cc of sterile saline. Statistical analysis was done using SPSS software. Results. The induction to delivery interval was 14.03 ± 7.61 hours versus 18.40 ± 8.02 hours (p < 0.01). The rate of vaginal delivery was 76.7% versus 56.8% in misoprostol and transcervical Foley catheter group, respectively. Uterine hyperstimulation was more common with misoprostol. Neonatal outcome was similar in both the groups. Conclusion. Intravaginal misoprostol is associated with a shorter induction to delivery interval as compared to Foley's catheter and it increases the rate of vaginal delivery in cases of unripe cervix at term. Transcervical Foley catheter is associated with a lower incidence of uterine hyperstimulation during labour.

Foley Catheter for Induction of Labor at Term: An Open-Label, Randomized Controlled Trial

Objective

This study aimed to determine the optimal Foley catheter balloon volume (30-mL vs. 80-mL) and the maximum time for cervical ripening (12 hours vs. 24 hours) to improve vaginal delivery rate within 24 hours of induction.

Methods

We conducted an open-label, randomized controlled trial in a teaching hospital in China. Women with a term singleton pregnancy, cephalic presentation, intact membrane and an unfavorable cervix (Bishop score <6) were randomly allocated, in 1:1:1:1 ratio, to receive either one of the four treatments: (1) 30-mL balloon for a maximum of 12 hours, (2) 30-mL balloon for a maximum of 24 hours, (3) 80-mL balloon for a maximum of 12 hours, and (4) 80-mL balloon for a maximum of 24 hours. The primary outcome was vaginal delivery within 24 hours. Secondary outcomes included cesarean section rate and maternal/neonatal morbidity. Data were analyzed on a per-protocol basis.

Results

Five hundred and four women were recruited and randomized (126 women in each group); nine women did not receive the assigned intervention. More women achieved vaginal delivery within 24 hours in 12-hour Foley catheter groups than in the 24-hour Foley catheter groups (30-mL/12 hours: 54.5%, 30-mL/24 hours: 33.1%, 80-mL/12 hours: 46.4%, 80-mL/24 hours: 24.0%, p < 0.001). Cesarean section rates and the incidence of chorioaminonitis were comparable among four groups. After adjustment for confounding factors, both ripening time and balloon size did not affect the proportion of women delivered vaginally within 24 hours of induction.

Conclusion

For women with an unfavorable cervix at term, induction of labor with a Foley catheter is safe and effective. Higher balloon volume (80-mL vs. 30-mL) and longer ripening time (24 hours vs. 12 hours) would not shorten induction to delivery interval or reduce cesarean section rate.

Trial Registration

Chinese Clinical trial registry (ChiCTR-TRC-13003044)

Is low dose vaginal misoprostol better than dinoprostone gel for induction of labor: a randomized controlled trial

OBJECTIVE

To compare the efficacy and safety profile of low dose vaginal misoprostol with dinoprostone gel for induction of labor in term pregnancies.

METHODS

The study was conducted at Lady Hardinge Medical College and Smt Sucheta Kriplani Hospital on 100 pregnant women with term pregnancy after application of inclusion and exclusion criteria. The women were randomized in 2 groups of 50 women each. Group I received misoprostol 25μg at every six hour vaginally for a maximum of five doses for induction of labor; while group II received dinoprostone gel 0.5 mg every six hourly for a maximum of three doses. Maternal outcomes such as mode of delivery and induction delivery interval; and fetal outcomes such as APGAR score and incidence of NICU admission were assessed in both the groups. Statistical analysis was done using student t-test and chi-square test.

RESULTS

There was no significant difference in the mean induction to delivery interval in both the groups (14.32±0.13 hours in Group I and 14.92±0.18 hours in Group II, p=0.75), mode of delivery, indication of cesarean section and perinatal outcome. However, significant difference was observed in requirement of oxytocin augmentation in both the groups (32% in Group I and 68% in Group II, p=0.005).

CONCLUSION

Vaginal misoprostol in low doses is similar in efficacy and safety to dinoprostone gel for cervical ripening and labor induction in term pregnancy.

Foley Catheter vs Prostaglandin as Ripening Agent in Pregnant Women With Premature Rupture of Membranes

Context: Although studies support the efficacy of the Foley catheter (FC) as a cervical ripening agent in pregnant women at term with intact membranes, its efficacy has not been well studied in women with premature rupture of membranes (PROM).

Objective: To compare the interval to delivery in women with PROM who underwent induction of labor and cervical ripening with mechanical (FC) vs nonmechanical (prostaglandin [PG]) cervical ripening agents.

Design: Retrospective medical record review at 2 hospitals of pregnant women who delivered between January 2009 and April 2011.

Setting: Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, and Christiana Care Health System in Newark, Delaware.

Patients: Pregnant women with singleton gestations 36 weeks or greater who presented with PROM.

Interventions: Cervical ripening with FC or PG.

Main Outcome Measures: The primary outcome was time from induction until delivery. Secondary outcomes included epidural use, maximum temperature during labor, number of vaginal examinations, occurrence of tachysystole, oxytocin dose, delivery mode, chorioamnionitis, and neonatal Apgar score.

Results: Of 155 medical records of patients who met the inclusion criteria, 33 women underwent cervical ripening with PG (ie, misoprostol) and 122 with FC. The interval to delivery was almost halved in women who underwent cervical ripening with FC compared with misoprostol (736 vs 1354 minutes; P<.01). Compared with the women in the misoprostol group, those in the FC group received a statistically significant higher dose of oxytocin (P<.01). There were no statistically significant differences between the groups with respect to the remaining secondary outcomes. Of note, all of the women who received FC were from Christiana Care Health System, and all women who received misoprostol were from Thomas Jefferson University Hospital.

Conclusion: Foley catheters may help shorten the interval to delivery in women who are candidates for cervical ripening after PROM at or near term. There does not appear to be an increased risk for cesarean delivery or chorioamnionitis in those treated with FC.

Induction of labour

OBJECTIVE

To review the most current literature in order to provide evidence-based recommendations to obstetrical care providers on induction of labour.

OPTIONS

Intervention in a pregnancy with induction of labour.

OUTCOMES

Appropriate timing and method of induction, appropriate mode of delivery, and optimal maternal and perinatal outcomes.

EVIDENCE

Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library in 2010 using appropriate controlled vocabulary (e.g., labour, induced, labour induction, cervical ripening) and key words (e.g., induce, induction, augmentation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to the end of 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The evidence in this document was rated using criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). SUMMARY STATEMENTS: 1. Prostaglandins E(2) (cervical and vaginal) are effective agents of cervical ripening and induction of labour for an unfavourable cervix. (I) 2. Intravaginal prostaglandins E(2) are preferred to intracervical prostaglandins E(2) because they results in more timely vaginal deliveries. (I).

Cervical ripening with Foley catheter for induction of labor after cesarean section: a cohort study

OBJECTIVE

To evaluate spontaneous vaginal delivery and complication rates after induction of labor with a transcervical Foley catheter in women with a previous cesarean delivery.

DESIGN

Retrospective cohort study.

SETTING

Secondary teaching hospital in the second largest city of the Netherlands.

POPULATION

Women with a history of cesarean delivery (n = 208), undergoing induction of labor with a Foley catheter in a subsequent pregnancy.

MATERIAL AND METHODS

The women who had induction of labor with a transcervical Foley catheter in the Ikazia Hospital, Rotterdam, between January 2003 and January 2012, were identified in a computerized database. Patient's records were checked for accuracy.

MAIN OUTCOME MEASURES

Vaginal delivery rate, cesarean section rate, uterine rupture and maternal and neonatal (infectious) morbidity.

RESULTS

Of the women 60% had a spontaneous vaginal delivery and 11% were delivered by vacuum extraction. Uterine rupture occurred in one woman. Postpartum hemorrhage was the most common maternal complication (12%). Maternal intrapartum and postpartum infections occurred in 5% and 1%. Proven neonatal infection was found in 3% of the cases. Two perinatal deaths occurred (1%), of which one was related to uterine rupture.

CONCLUSION

Induction of labor with a transcervical Foley catheter is an effective method to achieve vaginal delivery in women with a previous cesarean delivery. There is a low risk of uterine rupture and maternal and neonatal (infectious) morbidity in this cohort.