Comparative Study of Intra-cervical Foley’s Catheter and PGE2 Gel for Pre-induction Ripening (Cervical)

Aim

The success of induction of labor depends on the cervical status at the time of induction.

Objective

For effective cervical ripening both Foley’s catheter and PGE₂ gel are used. The aim of this study was to compare the efficacy of intra cervical Foley’s catheter and intra cervical PGE₂ gel in cervical ripening for the successful induction of labor.

Study Design

A randomized, prospective study was conducted in the Dept of OBGY, GMCH, Aurangabad from July 2005–January 2008. 400 patients at term with a Bishop’s score ≤3 with various indications for induction were randomly allocated to receive (200 pts) intra-cervical Foley’s catheter or PGE₂ gel (200 pts). After 6 h post induction, Bishop’s score was noted labor was augmented if required. Statistical analysis was done using Chi square test and t test.

Result

The groups were comparable with respect to maternal age, gestation age, indication of induction and initial Bishop’s score. Both the groups showed significant change in the Bishop’s score, 5.56 ± 1.89 and 5.49 ± 1.82 for Foley’s catheter and PGE₂ gel, respectively, P < 0.001; However there was no significant difference between the two groups. There was no significant difference in the side effects. Twenty eight cesarean sections (14%) were performed in Group A and 37 (18.5%) were performed in Group B (not significant). The induction to delivery interval was 15.32 ± 5.24 h in Group A and 14.2 ± 5.14 h in Group B (P = 0.291). Apgar scores, birth weights and NICU admissions showed no difference between the two groups.

Conclusion

This study shows that both Foley’s Catheter and PGE₂ gel are equally effective in pre induction cervical ripening.     

Premature Rupture of Membrane at Term: Early Induction Versus Expectant Management

Introduction

Premature rupture of membrane is managed either expectantly or actively. The purpose of the study was to assess the effectiveness of early labor induction with cervical prostaglandin E2 versus expectant management in women with term premature rupture of membrane.

Material and Methods

Singleton pregnancy cases with cephalic presentation reported between 37 and 41 weeks of pregnancy with PROM of <6 h and cervical dilatation <3 cm were studied over a period of 2 years. Out of 100 patients studied, half of them were managed by expectant protocol and the other half by early induction within 6 h of PROM with intracervical gel. Main outcomes measured were PROM–delivery interval, mode of delivery, neonatal and maternal morbidity, and period of maternal and/or neonatal hospitalization. Chi-square test was used to compare frequencies between two groups. Differences between means of other measurement were compared by independent t test.

Results

PROM–delivery interval was 22 h in expectant group, while in early induction group, it was 13 h (p value < 0.001). Rate of cesarean section remained almost same in both groups. Increases in maternal–neonatal infection rate and hospital stay were noted in expectant group; however, this was not statistically significant.

Conclusion

Immediate labor induction with prostaglandin in cases of term PROM shortens delivery interval and maternal hospital stay with reduction in maternal–neonatal sepsis.     

CLINICAL MANAGEMENT OF PREMATURE RUPTURE OF MEMBRANES

Premature rupture of membranes (PROM) is a common obstetric occurrence; yet, the management of a patient who presents with PROM is controversial. This article reviews the etiology of PROM, describes the evaluation of a patient who presents with PROM, and enumerates the pitfalls inherent in making the diagnosis. Research suggests that an expectant approach to PROM at term is preferable to immediate induction. The use of PGE₂ gel is an option for women who have unfavorable cervices. Clinical management of preterm premature rupture of membranes (PPROM) is generally expectant, with controversies surrounding the use of amniocentesis, corticosteroids, and tocolytics. Each of these topes is reviewed and current research summarized.     

Practicability of vaginal washing fluid creatinine level in detecting premature rupture of membranes

Objective

The purpose of this study was to evaluate the reliability of vaginal washing fluid creatinine level for the diagnosis of premature rupture of membranes (PROM).

Method

A prospective diagnostic study performed in Shahid Sedoughi Hospital on 160 pregnant women (30 definite PROM, 30 no PROM and 100 suspected PROM) at 28?C40?weeks of gestation. The vagina was washed by injection with a syringe filled with 3?ml of saline solution, and the washing fluid was collected from the posterior vaginal fornix and send to laboratory. Creatinine values in vaginal washing were measured and compared.

Result

The mean vaginal fluid creatinine levels in definite PROM group, suspected PROM and no PROM were 0.40?±?0.20, 0.16?±?0.04 and 0.08?±?0.01?mg/dl, respectively, where the difference was statistically significant (P?=?0.001). The sensitivity, specificity, positive and negative predictivity values and accuracy were 98.7, 100, 100, 98.8 and 87.1%, respectively, in detecting PROM by evaluation of vaginal fluid creatinine concentration with cut-off value of 0.14?mg/dl.

Conclusion

This study showed that creatinine determination in vaginal washing fluid is a useful marker for PROM diagnosis. It is a reliable, simple, cheap and rapid test.     

Comparative Study of Efficacy and Safety of Oral Versus Vaginal Misoprostol for Induction or Labour

Objective

To compare the efficacy of oral with vaginal misoprostol for induction of labour.

Design

A randomized trial.

Setting

Tertiary care hospital.

Participants

Two hundred women requiring induction of labour.

Methods

Group A received oral misoprostol 50 mcg 6 hourly maximum 4 doses to 100 patients and Group B received vaginal misoprostol 50 mcg 6 hourly maximum 4 doses to 100 patients. When the patient entered active stage of labour i.e. clinically adequate constractions of 3/10 min of >40 s duration, and cervical dilatation of with 4 cm, further doses of misoprostol were not administered. Statistical analysis was done using chi-square test and t test.

Result

Both groups were comparable with respect to maternal age, gestational age, indication of induction and initial modified Bishops score Mean number of dosage required for successful induction were significantly less in vaginal group than oral group (in oral groups A were 2.73 + 0.58, and in vaginal Group B 2.26 + 0.52, P value < 0.0001 highly significant). The induction delivery interval was significantly less in vaginal group than oral group (Group A 15.24 + 3.47 h Group B 12.74 + 2.60 h, P < 0.0001 highly significant). Oxytocin augmentation required was less in vaginal group. 26 caesarean sections were performed in oral group and 17 caesarean sections were done in vaginal group (P value 0.06 NS). APGAR score, birth weight, NICU admissions showed no difference between the two groups.

Conclusion

This study shows that vaginal route of administration of misoprostol is preferable to oral route for induction of labour when used in equivalent dosage of 50 mcg 6 hourly.     

A Comparison of Vaginal vs. Oral Misoprostol for Induction of Labor–Double Blind Randomized Trial

Objective

To compare efficacy and safety of 50 μgm misoprostol vaginal with oral for labor induction.

Methods

110 women at term gestation, Bishop score ≤4, with various indications for labor induction were randomized and double blinded. After decoding 51 women had received misoprostol orally and 52 vaginally, four hourly (maximum six doses) or till woman went into active labor.

Results

Statistical analysis was done with SPSS 11.0. In vaginal misoprostol group induction delivery interval was significantly less (9.79 vs. 16.47 h) and successful induction was significantly higher (90.38 vs. 74.51%) than oral group, with in 24 h of induction. As for as dose required is concerned in vaginal group 40.38% women needed two doses for delivery, in contrast 35.29% in oral group maximum six doses were required.

Conclusion

Vaginal route of misoprostol is more effective labor inducing agent than oral.     

Computational model for timing of delivery in an obese population

Objective: To estimate the impact on stillbirth risk, cesarean deliveries, and delivery-related healthcare cost associated with induction of labor compared to expectant management of term pregnancies in an obese population.

Methods: A decision analysis model was designed to compare the delivery and cost outcomes associated with a hypothetical cohort of 100,000 term pregnancies, complicated by obesity, that were planning a vaginal delivery. The model predicted stillbirths, cesarean deliveries, and total delivery-related health care cost from routine induction at 39 weeks compared to expectant management and routine induction each week from 40 to 42 weeks.

Results: There were 387 stillbirths avoided by routine induction at 39 weeks compared to the worst-case model of expectant management with induction at 42 weeks. 9234 cesarean deliveries were avoided by routine induction at 39 weeks compared to the worst-case model of expectant management and induction at 41 weeks (30,888 vs. 40,122) . Routine induction at 39 weeks showed a savings in delivery-related health care cost of 30 million dollars compared to the worst-case model of expectant management and induction at 41 weeks (536 million vs. 566 million).

Conclusion: Utilizing this computational model, routine induction at 39 weeks minimizes stillbirths, cesarean deliveries, and delivery-related health care cost.     

Comparison Between Use of Oral Misoprostol Versus Vaginal Misoprostol for Induction of Labour at Term

Background and Objective

In modern obstetrics, around 30% of cases require induction of labour for various reasons. Misoprostol is gaining popularity as pharmacological inducing agent, though the route and dosage of administration are not standardised. The objective of the study is to compare the safety and efficacy of the two routes of misoprostol administration—oral (100 μg 4th hourly) and vaginal (25 μg 4th hourly), for induction of labour at term.

Methods

In this randomised trial, 104 women having crossed the expected date of delivery without going into spontaneous labour and cases which had premature rupture of membranes <12 h were considered for labour induction and were divided into two equal groups. Group A received 100 μg misoprostol orally 4th hourly, and group B received 25 μg misoprostol vaginally 4th hourly. Labour characteristics and maternal and foetal outcome were compared.

Results

In terms of maternal outcome, mean number of doses for oral group is 2.73 and vaginal group is 3.04. In oral group, mean induction to vaginal delivery interval was 13 h 43 min and in vaginal group interval is 13 h 26 min which was statistically not significant. The need for oxytocin augmentation was also statistically not significant. Both groups had equal number of failed inductions. Emergency LSCS done for foetal distress was more in vaginal group 2.9% compared to oral group which is 1%, but difference was not statistically significant (p value ?0.55). Number of thick MSL in oral group was 3.2% as compared to vaginal group which is 10.7% which was statistically significant (p value ?0.04). APGAR score at 5 min 7/10 was seen in 7.7% in vaginal group as compared to 0% in oral group which was also statistically significant (0.004). Number of NICU admissions was also more in vaginal group compared to oral group.

Conclusion

Misoprostol in either oral or vaginal route has proven to be equally effective for inducing labour in women at term pregnancy. However, occurrence of lesser incidence of meconium-stained liquor and NICU admissions and fewer caesareans with better neonatal outcome in women induced with oral misoprostol outweighs its advantages over the vaginal misoprostol.

     

Orally Administered Misoprostol for Induction of Labor with Prelabor Rupture of Membranes at Term

Prelabor rupture of membranes (PROM) occurs in approximately 8% to 10% of women with term pregnancies. The management of PROM continues to be controversial. Approaches include expectant management and immediate induction of labor. The use of orally administered misoprostol for the management of women with PROM may provide significant advantages when they choose immediate induction of labor. This literature review presents current evidence that supports the use of oral misoprostol for women with PROM, including the benefits of a decreased interval time from PROM to vaginal birth, good safety profile, and reductions in the use of oxytocin augmentation and epidural anesthesia. In addition to clinically proven benefits to women of oral misoprostol for PROM, it also has the potential to reduce chorioamnionitis by reducing the number of sterile vaginal examinations performed thereby reducing the risk of ascending bacteria. Women have also reported acceptability and satisfaction when using oral misoprostol for immediate induction of labor. This review of literature discusses what is known about the use of orally administered misoprostol for the management of term PROM and makes recommendations for clinical use.     

PGE2 gel for enhancement of priming and induction of labour at term in patients with unfavourable cervix

Fifty women (25 nulliparae and 25 multiparae) with unfavourable cervix at term were enrolled in a clinical experiment to evaluate the safety and efficacy of the intracervical application of 0.5 mg PGE₂ gel for cervical softening and eventual induction of labour; duration of pregnancy (38–42 wk) was confirmed by ultrasonic records. Global analysis revealed 48 (96%) vaginal deliveries, 43 (86%) being spontaneous labour and 5 (10%) instrumentally assisted deliveries (forceps). Caesarean section was required in 2 cases (4%). Three patients, having registered no Bishop score (above 5) progress after the first treatment, went into labour upon the second application of PGE₂ gel. Mean induction-delivery time was 11 h 50 min for nulliparae and 7 h 50 min for multiparae. Mean ROM/amniotomy-delivery time was 5 h 59 min for nulliparae and 3 h 11 min for multiparae. Four neonates with initial Apgar scores below 7 registered immediately higher values after adequate reanimation manouvres.     

Signal quality of non-invasive fetal electrocardiogram in vaginal breech delivery: a case–controlled study

Objective

Recently, a non-invasive fetal electrocardiogram monitor has been approved for clinical usage in labour and delivery. To determine the fetal signal quality of vaginal breech deliveries in comparison with a case–controlled cephalic group during labour.

Study design

This case–control study was carried out at the Department of Obstetrics and Gynecology of the University Hospital Frankfurt between 1st July 2012 and 30th September 2012. A total of seven breech deliveries were evaluated. A case–controlled cephalic group with same gestational age and parity were selected from a previous trial.

Results

During first stage of labour, vaginal breech and cephalic delivery had no significant different fetal signal success rates (mean 87.8 vs. 85.7 %; p > 0.05). There was a trend of higher fetal signal success rates in the vaginal breech delivery group during second stage of labour (78.4 vs. 55.4 %; p = 0.08).

Conclusion

Similar fetal signal success rates in vaginal breech delivery in comparison to cephalic presentation were demonstrated using the new commercially available non-invasive abdominal fECG device (the Monica AN24^TM).     

Puerperal morbidity following repeat cesarean delivery in twin pregnancies

Objective

To evaluate the puerperal complications following twin deliveries.

Study design

We conducted a population-based analysis of puerperal delivery-related complications of twins born in Slovenia for comparing three groups of births (vaginal, elective and emergent cesarean).

Results

A total of 1,001 elective, 1,109 emergent cesarean sections, and 2,204 vaginal twin births were evaluated. No differences were found between the complications after emergent and elective cesareans. Uterine atony was more frequent after vaginal births (OR 1.8–2.0, 95 % CI 1.1–1.2, 2.9–3.3). Vaginal births had a higher frequency of endometritis compared with elective cesarean (OR 4.1, 95 % CI 1.2, 13.6). Conversely, vaginal deliveries were less frequently associated with anemia, hematoma formation, and need for blood transfusion as compared to both modes of cesarean deliveries.

Conclusion

No solid data exist to show a clear advantage or disadvantage in terms of puerperal complications of an elective cesarean over vaginal birth for twins.     

Sequential Versus Concurrent Use of Vaginal Misoprostol Plus Foley Catheter for Induction of Labor: A Randomized Clinical Trial

Background

To compare between the sequential and concurrent use of vaginal misoprostol plus Foley catheter for labor induction.

Methods

This single-center, non-blinded randomized study was conducted at the department of Obstetrics and Gynecology, Faculty of medicine, Zagazig University. A total of 160 women with full term singleton pregnancy, cephalic presentation and bishop score ≤ 6 were randomized for labor induction with either concurrent or sequential use of vaginal misoprostol plus Foley catheter (80 cases in each group). The primary outcome measured was induction-to-delivery interval and secondary outcomes mesaured were vaginal delivery within 24 h, number of doses needed to induce labor, need of oxytocin for augmentation of labor, cesarean section rate, maternal or neonatal complications.

Results

The mean induction-to-delivery interval was 22.33 ± 13.28 h versus 18.45 ± 14.34 h (p = 0.041) in sequential and concurrent group, respectively. The percentage of women who completed vaginal delivery within 24 h was 51% versus 61% (p = 0.046) in sequential and concurrent group, respectively. Other maternal and neonatal outcomes were similar in both groups

Conclusion

Concurrent use of vaginal misoprostol plus Foley catheter for labor induction was associated with shorter induction-to delivery interval compared to sequential use, and it increases the rate of vaginal delivery in the first 24 h.

     

Is nuchal cord justified as a cause of obstetrician anxiety?

Purpose

Birth asphyxia leading to acidosis comprises 20–60 % of perinatal mortality. Nuchal cord (NC) is one of the possible causes of birth asphyxia. Majority of fetuses who are antenatally detected to have nuchal cord are able to achieve successful vaginal birth. The purpose of this study was to analyze the effect of nuchal cord on fetal acid base status and perinatal outcome in vaginal deliveries.

Study design

150 parturients were equally divided into three groups after vaginal delivery based on no NC, single and multiple loops. Umbilical cord arterial blood was analyzed for biochemical markers i.e. pH, PO₂, SPO₂, PCO₂, HCO₃ ^?, standard base excess and lactate for acidosis. Labor complications like abnormal FHR, meconium-stained liquor, prolonged second stage, instrumental vaginal delivery, third stage complications were compared. In neonates, birth weight, Apgar score ≤7 at 5 min, NICU admission and other morbidity and mortality during hospital stay were compared among groups using suitable statistical tests. Above parameters were also compared between tight and loose loops.

Result

Nuchal cord groups had significantly higher frequency of labor complications than no NC group, especially tight loops. Neonates with NC had significantly higher frequency of meconium-stained liquor, Apgar score ≤7 at 5 min, deranged biochemical markers, NICU transfer. However, none of the neonate had pH in acidosis range and majority were discharged in healthy condition.

Conclusion

Patients with NC are likely to have uneventful labor and delivery as cord compression is transient and most fetuses are able to compensate for reduce umbilical blood flow. Routine antenatal ultrasound scan is not advisable, as mode of delivery and labor management does not change with detection of NC antenatally. Therefore, vaginal delivery with routine labor protocol can be allowed in cases of nuchal cord.     

Expectant versus surgical management of first-trimester miscarriage: a randomised controlled study

Introduction

The aim of this study is to compare the efficacy and safety of expectant management with surgical management of first-trimester miscarriage.

Methods

This randomised prospective study was conducted in the Gynaecology Department at University of Saarland Hospital, Germany between February 2011 and April 2012. A total of 234 women were recruited following diagnosis of the first-trimester incomplete or missed miscarriage and randomised into two groups: 109 women were randomised to expectant management (group I), and 125 women to surgical management (groupII). All women were examined clinically and sonographically during the follow-up appointments at weekly intervals for up to 4 weeks as appropriate. The outcome measures were: efficacy, short-term complications and duration of vaginal bleeding and pain.

Results

Of 234 eligible women, 17 were lost to follow-up, and the remaining 217 women were analysed. The baseline characteristics were similar in both groups. The total success rate at 4 weeks was lower for expectant than for surgical management (81.4 vs 95.7 %; P = 0.0029). The type of miscarriage was a significant factor affecting the success rate. For missed miscarriage, the success rates for expectant versus surgical management were 75 and 93.8 %, respectively. For women with incomplete miscarriage, the rates were 90.5 and 98 %. No differences were found in the number of emergency curettages between the two study groups. The duration of bleeding was significantly more in the expectant than the surgical management (mean 11 vs 7 days; P < 0.0001). The duration of pain was also more in the expectant than the surgical group (mean 8.1 vs 5.5 days; P < 0.0001). The total complication rates were similar in both groups (expectant 5.9 % vs surgical group 6.1 %; P = 0.2479). However, the pelvic infection was significantly lower in the expectant than the surgical group (1.9 vs 3.5 %, respectively; P = 0.0146).

Conclusion

Expectant management of clinically stable women with first-trimester miscarriage is safe and effective and avoids the need for surgery and the subsequent risk of anaesthesia in about 81.4 % of cases, and has lower pelvic infection rate than surgical curettage. However, surgical management is more successful, and with a shorter duration of bleeding and pain. Therefore, the patient’s preference should be considered in the counselling process.     

Non-invasively collected amniotic fluid as a source of possible biomarkers for premature rupture of membranes investigated by proteomic approach

Purpose

Preterm delivery is one of the main causes of perinatal morbidity and mortality and it accounts for 75 % of perinatal mortality and more than half of the long-term morbidity. We applied a proteomic approach based on mass spectrometry (MS) for biomarkers discovery of preterm premature rupture of membranes (pPROM) by investigating amniotic fluid (AF) invasively and non-invasively collected.

Methods

Amniotic fluid was obtained from vagina of women with pPROM (group 1), PROM at term (group 2) and by genetic amniocentesis (group 3). Pre-fractionated AF proteome was analyzed through matrix assisted laser desorption ionization-time of flight (MALDI-TOF) MS. The characterization of proteins/peptides of interest was obtained by high performance liquid chromatography–electrospray tandem MS.

Results

Three peptides overexpressed in pPROM and able to discriminate the groups 1 and 2 were detected. One peptide was identified as the fragment Gly₄₅₂LAVPDGPLGLPPKPro₄₆₆ of the protein KIAA1522, expressed by fetal brain and liver. This peptide was overexpressed in a patient of the group 3, completely asymptomatic at the time of the amniocentesis, who later developed pPROM.

Conclusion

Amniotic fluid invasively and non-invasively collected can be analyzed by MALDI-TOF MS to obtain proteomic profiles. Proteomic analysis identified a peptide with promising diagnostic capability for pPROM.     

Labor induction just after external cephalic version with epidural analgesia at term

Objective

To analyze the benefits of external cephalic version (ECV) with epidural analgesia at term and labor induction just after the procedure.

Restricted use of episiotomy

Objective

To compare the outcome of restricted versus routine use of episiotomy in a tertiary care center.

Method

A prospective observational study was conducted for singleton normal vaginal term deliveries. Deliveries managed with routine use of episiotomy formed the ‘Control Group’, while those managed with restricted use of episiotomy formed the ‘Study Group’. Data so obtained was analyzed.

Results

Total number of deliveries analyzed was 458 (‘Control Group’: n=210, ‘Study Group’: n=248). Restricted use of episiotomy led to 64% (n=159) women delivering without any perineal laceration, in ‘Study Group’. This translated into 41% (n=38) reduction in the number of perineal lacerations in primipara, and 23% (n=36) in multipara, compared to the ‘Control Group’. Only 2% of primipara in ‘Study Group’ had severe third degree perineal tears.

Conclusion

Restricted use of episiotomy resulted in considerable reduction in maternal morbidity due to perineal lacerations.     

Economic analysis comparing induction of labour and expectant management for intrauterine growth restriction at term (DIGITAT trial)

Objective

Pregnancies complicated by intrauterine growth restriction (IUGR) are at increased risk for neonatal morbidity and mortality. The Dutch nationwide disproportionate intrauterine growth intervention trial at term (DIGITAT trial) showed that induction of labour and expectant monitoring were comparable with respect to composite adverse neonatal outcome and operative delivery. In this study we compare the costs of both strategies.

Study design

A cost analysis was performed alongside the DIGITAT trial, which was a randomized controlled trial in which 650 women with a singleton pregnancy with suspected IUGR beyond 36 weeks of pregnancy were allocated to induction or expectant management. Resource utilization was documented by specific items in the case report forms. Unit costs for clinical resources were calculated from the financial reports of participating hospitals. For primary care costs Dutch standardized prices were used. All costs are presented in Euros converted to the year 2009.

Results

Antepartum expectant monitoring generated more costs, mainly due to longer antepartum maternal stays in hospital. During delivery and the postpartum stage, induction generated more direct medical costs, due to longer stay in the labour room and longer duration of neonatal high care/medium care admissions. From a health care perspective, both strategies generated comparable costs: on average €7106 per patient for the induction group (N = 321) and €6995 for the expectant management group (N = 329) with a cost difference of €111 (95%CI: €−1296 to 1641).

Conclusion

Induction of labour and expectant monitoring in IUGR at term have comparable outcomes immediately after birth in terms of obstetrical outcomes, maternal quality of life and costs. Costs are lower, however, in the expectant monitoring group before 38 weeks of gestation and costs are lower in the induction of labour group after 38 weeks of gestation. So if induction of labour is considered to pre-empt possible stillbirth in suspected IUGR, it is reasonable to delay until 38 weeks, with watchful monitoring.     

Vaginal Misoprostol vs Vaginal Misoprostol With Estradiol for Labor Induction: A Prospective Double Blind Study

Objective

To compare the safety and effectiveness of vaginal misoprostol with combined vaginal misoprostol and estradiol for induction of labor in unfavorable cervix.

Method

A prospective study was carried out from Jan 2008 to Jul 2008 on total of 90 women with unfavorable cervix (Bishop’s score was <5) and gestation >36 weeks with clinical indication for induction of labor. They were randomly assigned to receive either vaginal misoprostol 25 μg alone or vaginal misoprostol 25 μg with vaginal estradiol 50 μg. Misoprostol alone was repeated every 3 h in both groups till ripening of cervix (Bishop’s score was = 8) and establishment of active labor.

Results

Main indications were post dated pregnancies (period of gestation >41 weeks) and pregnancy induced hypertension. Age, parity and mode of delivery were not significantly different. No significant difference was found in pre induction Bishop’s score, fetal outcome and maternal complications. However, doses of misoprostol required for cervical ripening (p = 0.017), time required for cervical ripening (p = 0.042), time required for starting of active labor (p = 0.017) and time required for delivery in vaginal delivery cases (p = 0.047) were found significantly less in combined estradiol and misoprostol group.

Conclusion

Estradiol acts synergistically with misoprostol vaginally and significantly hastens the process of cervical ripening, initiation of active labor and vaginal delivery.