Controlled-release dinoprostone insert versus Foley catheter for labor induction: a meta-analysis

Objective: To compare the effectiveness and safety of controlled-release dinoprostone insert with Foley catheter balloon for cervical ripening and labor induction.

Methods: PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and China Knowledge Resource Integrated Database were searched. Only randomized controlled trials comparing controlled-release dinoprostone insert with Foley catheter balloon were included. Risk ratio (RR) or mean difference (MD) with 95% con?dence interval (CI) was calculated.

Results: Six studies were included with 731 women received dinoprostone insert and 722 Foley catheter. Time from induction to delivery was significantly shortened in dinoprostone insert group compared to Foley catheter group (MD 5.73 h, 95% CI 1.26–10.20). There were no significant differences in vaginal delivery within 24 h (RR 0.75, 95% CI 0.43–1.30) or cesarean section (RR 0.94, 95% CI 0.80–1.12) between two ripening methods. Dinoprostone insert was related with increased rate of excessive uterine contraction (RR 0.07, 95% CI 0.03–0.19), but less oxytocin use (RR 1.86, 95% CI 1.25–2.77) when compared with Foley catheter.

Conclusions: Induction of labor with controlled-release dinoprostone insert seems to be more effective than Foley catheter. However, the former method causes excessive uterine contraction more frequently.     

A randomized trial comparing vaginal misoprostol versus Foley catheter with concurrent oxytocin for labor induction in nulliparous women

The objective of this study was to compare the efficacy and safety of intracervical Foley catheter with concurrent use of oxytocin versus vaginal misoprostol for labor induction in nulliparous women. Nulliparous women with Bishop score <6 who presented for labor induction were randomized to either 25 microg vaginal misoprostol every 4 hours followed by oxytocin, if indicated, or intracervical Foley catheter with simultaneous use of oxytocin. Among the 162 patients enrolled, 79 (49%) received misoprostol and 83 (51%) received Foley/oxytocin. We were unable to demonstrate a statistically significant difference between the misoprostol group and Foley/oxytocin group in the incidence of cesarean delivery (35% versus 29%; p = 0.37). The induction-to-delivery time was significantly shorter in the Foley/oxytocin group (18 versus 24 hours; p < 0.01). No differences in intrapartum complications, neonatal outcomes, or maternal morbidity were found. When compared with vaginal misoprostol, intracervical Foley catheter combined with oxytocin has a similar efficacy and safety profile for labor induction in nulliparous women. Foley/oxytocin results in a shorter induction-to-vaginal delivery time compared with misoprostol.     

Foley catheter versus intravaginal prostaglandins E2 for cervical ripening in women at term with an unfavorable cervix: a randomized controlled trial

Objective: The objective of this study is to compare the efficacy of labor induction by Foley catheter balloon (FCB) insertion to intravaginal dinoprostone tablet placement in women with an unfavorable cervix.

Materials and methods: A prospective randomized controlled trial was conducted. Women were assigned to insertion of a FCB or placement of a vaginal dinoprostone tablets and their outcome were compared.

Results: The study comprised 300 women. The time to active labor was significantly shorter in the FCB compared with the dinoprostone group, but required more oxytocin administration. A lower rate of cesarean section was found only in nulliparous women in the FCB group. The neonatal outcome was favorable and similar in both groups.

Conclusion: Both methods had similar results regarding achieving vaginal delivery within 24?h and cesarean section rate. For nulliparous women, the FCB induction method had the advantage of a shorter time to active labor and a lower rate of cesarean section.     

Transcervical Foley catheter with and without oxytocin for cervical ripening: a randomized controlled trial

OBJECTIVE: To estimate whether adding oxytocin to transcervical Foley catheter preinduction cervical ripening improves induction success. METHODS: This trial enrolled 200 women with singleton pregnancies presenting for preinduction ripening. Patients were randomly assigned to receive either Foley catheter alone (control) or Foley catheter plus low-dose oxytocin (treatment). Providers were not blinded to use of oxytocin, and labor was managed according to routine obstetric protocols. This study was powered to detect a 20% difference in the proportion of patients delivered within 24 hours. Secondary outcomes were related to vaginal delivery rate, duration of induction, complications, and pain management. RESULTS: Results were available for 183 (92 treatment, 91 control) of 200 patients randomly assigned. There were no differences in proportions of deliveries-overall (65% compared with 60%; relative risk [RR] 1.08, 95% confidence interval [CI] 0.86-1.35, number needed to treat 21) or vaginal (48% compared with 46%; RR 1.04, 95% CI 0.76-1.41, number needed to treat 60)-in 24 hours, or cesarean deliveries or times to deliveries between treatment or control groups. Rates of complications were comparable; however, the treatment group had a higher proportion of regional analgesia requirement during induction than controls (23% compared with 9%, P=.01; RR 2.60, 95% CI 1.21-5.56). CONCLUSION: Addition of oxytocin to transcervical Foley catheter does not shorten the time to delivery and has no effect on the likelihood of delivery within 24 hours or vaginal delivery rate, although there is an increased use of analgesia by these patients during ripening. The use of oxytocin in addition to Foley catheter ripening is not justified. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00468520. LEVEL OF EVIDENCE: I.     

Cervical ripening: A randomized comparison between intravaginal misoprostol and an intracervical balloon catheter combined with intravaginal dinoprostone

OBJECTIVES: Our purpose was to compare the efficacy of intravaginal misoprostol and intracervical Foley catheter/intravaginal dinoprostone for cervical ripening. STUDY DESIGN: Patients admitted for induction of labor were randomized to receive intravaginal misoprostol 25 μg every 4 hours or intracervical Foley catheter/intravaginal dinoprostone 4 mg every 4 hours. Patients not entering active labor and having ruptured membranes or arrest of dilatation received intravenous oxytocin. RESULTS: Sixty-five patients received Foley catheter/dinoprostone gel and 62 patients received misoprostol. The mean time until cervical ripening was less in the catheter/gel group (7.5 ± 3.4 vs 12.0 ± 5.9 hours, p < 0.01). The mean time until vaginal delivery was less in the catheter/gel group (17.4 ± 6.9 vs 21.2 ± 7.5 hours, p = 0.004). Among vaginal deliveries, more patients in the catheter/gel group delivered within 24 hours (90% vs 69%, p = 0.013). CONCLUSIONS: Intracervical Foley catheter/intravaginal dinoprostone was associated with more rapid cervical ripening, shorter induction to vaginal delivery interval, and greater number of vaginal deliveries within 24 hours. (Am J Obstet Gynecol 1998;178:1333-40.)     

Cervical assessment in women with threatened preterm labor

Objective.?The aim of the study was to examine the clinical value of cervical assessment by transvaginal ultrasonography in women with symptoms of preterm labor.

Methods.?We prospectively evaluated 172 women with singleton pregnancies and symptoms of preterm labor. Seventy of them were nulliparas, while 102 were multiparas. Gestational age ranged between 24 and 34 wks. All women underwent cervical assessment with transvaginal ultrasonography and were given intravenous tocolytics. The only parameter evaluated was cervical length. Women with multiple pregnancies, gestational age <?24 wks or >?34 wks, cervical dilatation >?2?cm, placenta praevia, premature rupture of membranes, or cervical cerclage were excluded from the study. The outcome measure was delivery before 34 wks gestation.

Results.?The preterm delivery rate before 34 wks was 37%. The sensitivity and the specificity of a cervical length of less than 20?mm was 60 and 53.8% and 97.7 and 95.2% for nulliparas and multiparas, respectively. A cervical length <?20?mm was also 93.7% predictive of preterm delivery in nulliparas and 87.5% in multiparas, while the corresponding numbers for its negative predictive value (NPV) were 81.4 and 76.9%, respectively.

Conclusions.?Cervical assessment in women with symptoms of preterm labor can distinguish those at high risk for preterm delivery. Cervical sonography can be a valuable adjunct to the clinical evaluation of these patients.     

Outcome in obstetric care related to oxytocin use. A population-based study

BACKGROUND: The purpose of this study was to investigate the delivery outcome in relation to oxytocin use in labor. METHODS: We studied 106,755 deliveries from 1995 to 2002 in the Perinatal Revision South, a population-based register comprising information from 10 hospitals in southern Sweden. RESULTS: Oxytocin use in labor increased from 27.6% in 1995/96 to 33.2% in 2001/02 (p<0.000006). Oxytocin was administered to 47.7% of the nulliparas and 18.5% of the multiparas. There were large differences between hospitals (range among nulliparas: 32.6-60.4%; among multiparas: 13.9-27.0%). After exclusion of deliveries with induction of labor and deliveries lasting >12 h, there was a significant association between oxytocin use and Apgar score < 7 at 5 min (OR 2.3; 95% CI 1.8-2.9), need for neonatal intensive care (OR 1.6; 95% CI 1.5-1.7), and operative delivery (OR 4.0; 95% CI 3.7-4.2). CONCLUSIONS: In deliveries with relatively short duration (< or =12 h), a significant association was seen between oxytocin use and adverse outcome. Even though the results are difficult to interpret, the significant difference between the use of oxytocin in different hospitals, as well as the increase of oxytocin use over time, calls for a randomized controlled study to elucidate the advantages and disadvantages of oxytocin use during labor and delivery.     

Membrane sweeping in conjunction with labor induction

OBJECTIVE: To determine whether cervical membrane sweeping (stripping) during induction of labor is beneficial.METHODS: We compared outcomes of labor after induction in pregnant women at term in a randomized trial. Women were assigned to having their membranes swept or not during induction. Outcome measures included duration of labor, maximum dose of oxytocin used, induction-labor interval, and mode of delivery.RESULTS: We recruited 130 nulliparas (64 sweep, 66 nonsweep) and 118 multiparas (60 sweep, 58 nonsweep). Among nulliparas who received intravaginal prostaglandin (PG) E(2) and oxytocin, those who had simultaneous sweeping had significantly shorter mean (+/- standard error of mean) induction-labor interval (13.6 +/- 1.4 versus 17.3 +/- 1.2 hours, P =.048), lower mean maximum dose of oxytocin (6.8 +/- 0.8 versus 10.35 +/- 1.1 mU/minute, P =.01), and increased normal delivery rates (vaginal delivery 83. 3% versus 58.2%, P =.01). Sweeping also had a favorable effect on nulliparas who received oxytocin alone (mean induction-labor interval 5.8 +/- 3.1 versus 11.2 +/- 3.6 hours, P =.04; mean maximum dose 8.8 +/- 1.3 versus 16.3 +/- 1.9 mU/min, P =.01). Those differences were limited to women with unfavorable cervices. There were no differences in any outcome measures in multiparous women. CONCLUSION: Sweeping of the membranes during induction of labor had a beneficial effect on labor and delivery, which appeared to be limited to nulliparas with unfavorable cervices who needed cervical priming with PGE(2).     

Foley catheter versus intra-vaginal misoprostol for induction of labor in post-term gestations

Objective

To investigate whether a fluid filled intra-uterine extra-amniotic Foley catheter is an effective alternative to vaginal misoprostol in inducing labor in primigravid women with post-term gestations.

Patients and methods

A prospective quasi-randomized controlled trial was designed and 100 primigravid women with post-term gestations were enrolled and equally allocated into two groups. A fluid filled intra-uterine extra-amniotic Foley catheter was inserted in women of group I. Women in group II received 25 microgram misoprostol vaginally every 4?h. Artificial rupture of membranes was performed for all women when their cervices reached 3?C4?cm dilatation followed by oxytocin infusion if needed. The main primary outcome parameter was the induction to delivery interval. Results were tabulated and statistically analyzed.

Results

No significant difference was noted in any of the demographic data between both groups. The induction to delivery interval was shorter in the Foley group (897.36?±?116.0 vs. 960.98?±?94.18?min; P?=?0.003). There were 34 cases which needed oxytocin augmentation in group I compared to 11 cases in group II (P?Conclusion Fluid filled Foley catheter seems to be superior to 25???g vaginal misoprostol regimen, when used to induce labor in primigravidae with post-term gestations with the advantage of having a shorter induction delivery interval, but more need for oxytocin augmentation.     

Is membrane sweeping beneficial at the initiation of labor induction?

Objective: To determine whether cervical membrane sweeping during labor induction is beneficial.

Methods: Outcomes of labor after induction in pregnant women at term were compared in a randomized trial. Women were assigned to having their membranes “swept” or “not swept” at the initiation of labor induction.

Results: We recruited a total of 870 women of which 70 were excluded. There were 400 nullipara (Group A) [198 “swept”, 202 “not swept”] and 400 multiparas (Group B) (201 “swept” and 199 “not swept”]. Among group A who received intravaginal prostaglandin (PG) E₂, those who had simultaneous sweeping had significantly shorter mean induction-labor interval (12.9?±?1.3 versus 16.2?±?1.1 hours, p?=?0.046), lower mean dose of oxytocin (6.6?±?0.6 versus 10.11?±?1.4?mU/minute, p?=?0.01), and increased normal delivery rates (vaginal delivery 82.8% versus 58.6%, p?=?0.01). Sweeping also had a favorable effect on nulliparas who had ARM and received oxytocin alone (mean induction-labor interval 5.9?±?2.9 versus 10.9?±?2.6 hours p?=?0.04, mean maximum dose of oxytocin 9.8?±?1.1 versus 15.2?±?1.1?mU/min, p?=?0.01). These results were restricted to women with unfavorable cervix in Group A those who had membrane sweeping.

Conclusion: Membrane sweeping, has beneficial effects on labor and delivery, which is limited to nulliparas with unfavorable cervix requiring PGE₂ or Oxytocin alone.     

Cervical ripening with transcervical foley catheter and the risk of uterine rupture

OBJECTIVE: To estimate whether the rate of uterine rupture in patients with a previous cesarean delivery is related to labor induction and/or cervical ripening using transcervical Foley catheter. METHODS: Charts of all patients who had a trial of labor after a previous cesarean delivery in our institution between 1988 and 2002 were reviewed. The rates of successful vaginal birth after cesarean delivery and uterine rupture in patients with spontaneous labor (control group) were compared with those of patients who underwent a labor induction by means of amniotomy with or without oxytocin and patients who underwent a labor induction/cervical ripening using a transcervical Foley catheter. Logistic regression analysis was performed to adjust for confounding variables. RESULTS: Of 2479 patients, 1807 had a spontaneous labor, 417 had labor induced by amniotomy with or without oxytocin, and 255 had labor induced by using transcervical Foley catheter. The rate of successful vaginal birth after cesarean delivery was significantly different among the groups (78.0% versus 77.9% versus 55.7%, P <.001), but not the rate of uterine rupture (1.1% versus 1.2% versus 1.6%, P =.81). After adjusting for confounding variables, the odds ratio (OR) for successful vaginal birth after cesarean delivery was 0.68 (95% confidence interval [CI] 0.41, 1.15), and the OR for uterine rupture was 0.47 (95% CI 0.06, 3.59) in patients who underwent an induction of labor using a transcervical Foley catheter when compared with patients with spontaneous labor. CONCLUSION: Labor induction using a transcervical Foley catheter was not associated with an increased risk of uterine rupture.     

Efficacy and safety of misoprostol compared with the dinoprostone for labor induction at term: a meta-analysis

Objective: The purpose of this study was to compare the efficacy and safety of intravaginal misoprostol and the dinoprostone vaginal insert for labor induction at term.

Method: PubMed, EMBASE, MEDLINE, CNKI, EBSCO and the Cochrane Library were searched for articles published in English language from 2000 to 2014, Using the keywords misoprostol, dinoprostone, labor induction.

Results: Eight of 436 studies (1669 women) identified met the criteria for meta-analysis. We assigned a quality rating to each included article. The use of misoprostol showed less oxytocin augmentation when compared with dinoprostone (RR?=?0.78, 95% CI?=?0.67–0.90). There was no difference in the risk of tachysystole (RR?=?1.18, 95% CI?=?0.78–1.79), uterine hyperstimulation (RR?=?1.24, 95% CI?=?0.75–2.06), vaginal delivery within 24?h (RR?=?1.10, 95% CI?=?1.00–1.20), cesarean delivery (RR?=?0.84, 95% CI?=?0.56–1.24), Neonatal Intensive Care Unit admission (RR?=?0.86, 95% CI?=?0.58–1.28), Apgar scores <7 in 5?min (RR?=?1.18, 95% CI?=?0.39–3.63) between misoprostol and dinoprostone.

Conclusion: Misoprostol compared with dinoprostone appears to show less oxytocin augmentation for labor induction at term. The other outcomes of both drugs were similar. However, these findings were based on small-scale trials. Further studies assessing the effectiveness and safety of misoprostol and dinoprostone in selected groups of patients are warranted.     

A comparison of obstetrical outcomes with labor induction agents used at term

Abstract

Objective: To compare the obstetrical outcomes of term pregnancies induced with one of four commonly used labor induction agents.

Methods: This is a retrospective cohort study of induced deliveries between 1 August 1995 and 31 December 2007 occurring at the Los Angeles County?+?University of Southern California Medical Center. Viable, singleton, term pregnancies undergoing induction were identified. Exclusion criteria included gestational age less than 37 weeks, previous cesarean delivery, breech presentation, stillbirth, premature rupture of membranes, and fetal anomaly. Induction methods studied were oxytocin, misoprostol, dinoprostone and Foley catheter. Our primary outcome was cesarean delivery rate among the four induction agents. Secondary outcomes included rate of failed induction, obstetrical complications, and immediate neonatal complications.

Results: A total of 3707 women were included in the study (1486 nulliparous; 2221 multiparous). Outcomes were compared across induction methods using Chi-square Tests (Pearson or Fisher’s, as appropriate). Among the nulliparous patients, there was no statistical difference among the four induction agents with regards to cesarean delivery rate (p?=?0.51), frequency of failed inductions (p?=?0.49), the cesarean delivery frequency for “fetal distress” (p?=?0.82) and five minute Apgar score <7 (p?=?0.24). Among parous patients, the cesarean delivery rate varied significantly by induction method (p?<?0.001), being lowest among those receiving misoprostol (10%). Those receiving oxytocin and transcervical Foley catheter had cesarean rates of 22%, followed by dinoprostone at 18%. The rate of failed inductions was 2% among those receiving misoprostol, compared to 7–8% among those in the other groups (p?<?0.01). Although cases of “fetal distress” between the four induction agents was not significantly different amongst multipara women, the cesarean delivery indication for “fetal distress” was higher among multipara receiving misoprostol (p?=?0.004). There was no difference among the different induction agents with regards to five minute Apgar <7 (p?=?0.34).

Conclusion: Among nulliparous women, all induction methods have similar rate of cesarean delivery. The use of misoprostol appears to be associated with a lower risk of cesarean birth among parous women induced at our institution.     

Labor induction in women with an unfavorable Bishop score: randomized controlled trial of intrauterine Foley catheter with concurrent oxytocin infusion versus Foley catheter with extra-amniotic saline infusion with concurrent oxytocin infusion

OBJECTIVES: This study was undertaken to determine whether the addition of extra-amniotic saline infusion improves the efficacy of the Foley catheter in women undergoing cervical ripening and induction of labor with an unfavorable cervical examination. STUDY DESIGN: One hundred consenting women with a Bishop score less than 5 with singleton gestation, intact membranes, vertex presentation, who required induction of labor were randomly assigned to 2 groups: Foley alone (Foley, n=49) or to the Foley catheter with extra-amniotic saline infusion (EASI, 30 mL of NS per hour infused through the distal port of the Foley, n=51). All women received concurrent dilute oxytocin infusion per protocol. The primary analysis was intent to treat. Nonparametric tests were used as indicated. RESULTS: At randomization, the groups were well balanced for potential confounders including: parity, gestational age, prior cesarean delivery, preeclampsia, mean dilation, effacement, and Bishop score. There were no differences between the groups for time to delivery (Foley 17.7 +/- 10.5 hours vs EASI 17.4 +/- 11.7 hours, P=.9), the proportion of women delivered before 24 hours (Foley 41/49 [84%] vs EASI 39/51 [77%], P=.37) or cesarean rates (Foley 9/49 [17.7%] vs EASI 9/51 [18.4%], P=.92). There were also no differences in complications, including chorioamnionitis, endometritis, and neonatal morbidity. CONCLUSION: EASI does not increase the efficacy of cervical ripening and induction of labor with a Foley catheter and concurrent oxytocin infusion.     

Comparison of labor progression between induced and noninduced multiparous women

OBJECTIVE: The incidence of labor induction is rising rapidly in the United States. Among multiparas, labor is often followed with traditional labor curves derived from noninduced pregnancies. We sought to determine how labor progression of multiparous women who presented in spontaneous labor differed from those who were electively induced with and from those induced without preinduction cervical ripening. METHODS: We analyzed data on all low-risk multiparous women with an elective induction or spontaneous onset of labor between 37(+0) and 40(+6) weeks of gestation from January 2002 to March 2004 at a single institution. The median duration of labor by each centimeter of cervical dilatation and the risk of cesarean delivery were computed for 61 women with preinduction cervical ripening and oxytocin induction, 735 women with oxytocin induction, and 1,885 women with a spontaneous onset of labor. An intracervical Foley catheter was used to ripen the cervix. RESULTS: Those women who experienced electively induced labor without cervical ripening had a shorter active phase of labor than did those admitted in spontaneous labor (99 minutes in induced labor versus 161 minutes in spontaneous labor, P < .001). However, the cesarean delivery rate was elevated in the induction group (3.9% versus 2.3%, P < .05). Women who underwent preinduction cervical ripening also had a shorter active phase than those admitted in spontaneous labor (109 minutes versus 161 minutes, P = .01). CONCLUSION: The pattern of labor progression differs for women with an electively induced labor without cervical ripening compared with those who present with spontaneous onset of labor.     

Comparing vaginal misoprostol versus Foley catheter plus vaginal isosorbide mononitrate for labor induction

Objective(S): To compare the effectiveness and safety of intra-cervical Foley catheter combined with intra-vaginal isosorbide mononitrate (IMN) versus intra-vaginal misoprostol for cervical ripening and labor induction in pregnant women with unripe cervices.

Methods: Open-labeled randomized controlled trial in Cairo university hospital, Cairo, Egypt during 2012–2014. Three hundred and ninety-five pregnant women at term or post-term with an indication for labor induction and unripe cervix were included in the study. The subjects were randomly divided into two groups. Vaginal misoprostol was used in group 1 (n?=?197) and intra-cervical Foley catheter plus vaginal IMN in group 2 (n?=?198). Our main outcome measure was cesarean section rate.

Results: Among the 395 included patients there were significantly lower duration of induction of labor (p?<?0.001) in group 1with lower cesarean section rates [22.8% in group 1versus 33.3% in group 2; RR 0.7 (0.6–0.9), (p?=?0.020)]. Whereas the uterine hyperstimulation (p?<?0.001) was significantly higher in group 1. There were no significant differences between both groups as regard patients’ demographic characteristics.

Conclusions(s): Vaginal misoprostol is more effective but less safe than Foley catheter combined with vaginal IMN for induction of labor in term and post-term pregnancy.     

Hyaluronidase versus Foley catheter for cervical ripening in high-risk term and post term pregnancies.

OBJECTIVE: To evaluate the effectiveness and safety of Foley catheter and hyaluronidase for cervical ripening. METHOD: Randomized controlled trial where 140 pregnant women, with gestational age > or = 37 weeks, indication for labor induction and an unripe cervix, were enrolled, allocated in two groups according to the method of cervical ripening before labor induction. Statistical analysis used Student's t-test, Mann-Whitney, Chi-square test, survival analysis, risk ratios and number needed to treat. RESULTS: Time of induction, dose of oxytocin and mode of delivery had better results in the Foley catheter group. Comfort with the method was higher in the hyaluronidase group. CONCLUSIONS: Both methods were effective and safe for cervical ripening. The Foley catheter group experienced a shorter period of induction, required a lower dose of oxytocin and had higher vaginal delivery rates, while the women who used hyaluronidase declared greater comfort with the method.     

Predictors of cesarean delivery in women undergoing labor induction with a Foley balloon

Objective: To examine predictive characteristics for cesarean delivery (CD) in women undergoing labor induction with a Foley balloon (FB).

Methods: A secondary analysis of a randomized, double-blind, control trial examining labor induction with a transcervical 30?mL or 60?mL FB. One-hundred ninety-nine women with term, vertex, singleton pregnancies and Bishop score Results: Increasing maternal age (p?=?0.04), nulliparity (p?=0.002) and chorioamnionitis (p?Conclusion: In patients undergoing labor induction with a FB, increasing maternal age, nulliparity and chorioamnionitis are associated with an elevated risk for CD.     

Impact of labor induction,gestational age,and maternal age on cesarean delivery rates

OBJECTIVE: To quantify the impact of labor induction and maternal age on cesarean delivery rates in nulliparous and multiparous women between 36 and 42 weeks' gestation. METHODS: We performed a retrospective cohort study on 14,409 women delivering at two teaching hospitals in metropolitan Boston during 1998 and 1999. Women who had contraindications to labor, including a prior cesarean delivery, were excluded. The risks for cesarean delivery by induction status, gestational age by completed week between 36 and 42 weeks, maternal age <35, 35-39, and >/=40 years, and stratified by parity, were calculated by logistic regression. RESULTS: In nulliparas, labor induction was associated with an increase in cesarean delivery from 13.7% to 24.7% (adjusted odds ratio [OR] 1.70; 95% confidence interval [CI] 1.48, 1.95]). In multiparas, induction was associated with an increase from 2.4% to 4.5% (OR 1.49; 95% CI 1.10, 2.00). Other variables that placed a nulliparous woman at increased risk for cesarean delivery included maternal age of at least 35 years and gestational ages over 40 weeks. For multiparas, only maternal age 40 years or older and gestational age of 41 weeks were associated with an increase in cesarean deliveries. CONCLUSION: Induction of labor, older maternal age, and gestational age over 40 weeks each independently increase the risk for cesarean delivery in both nulliparous and multiparous women. Although the relative risk from induction is similar in nulliparas and multiparas, the absolute magnitude of the increase is much greater in nulliparas (11% versus 2.1%).     

Sequential use of Foley catheter with misoprostol for second trimester pregnancy termination in women with and without caesarean scars: a prospective cohort study

Purpose: The aim of this study is to evaluate the effectiveness and safety of misoprostol and Foley catheter in second trimester termination in women with and without caesarean section (CS) scars.

Materials and methods: Women with an indication for pregnancy termination between 14 and 22 completed weeks of gestation were included to the study. Enrolled women were allocated into three groups: (1) women with no history of CS, (2) women with one CS and (3) women with ≥2 CS. Study consisted 337 patients (233 group 1, 88 group 2 and 16 group 3). Misoprostol and Foley catheter were used sequentially. The primary outcome was the induction to abortion interval. Secondary outcomes were the successful vaginal abortion rate, the percentage of abortions in 24?h and the rates of surgical removal of the placenta, Foley catheter use and major maternal complications (transfusions, thromboembolic events, uterine rupture and death).

Results: Demographic characteristics were comparable. All study outcomes were statistically similar among groups. There was no major maternal complication among all patients.

Conclusions: Sequential use of misoprostol and Foley catheter is safe and effective in second trimester pregnancy termination for patients with and without CS scars.