Cervical Ripening

The purpose of this study was to evaluate the efficacy of adding laminaria tents to sequential intravaginal prostaglandin E₂ (PGE₂) gel for cervical ripening.

A prospective, randomized study was conducted from October 1994 to May 1995. Pregnant women with maternal or fetal indications for induction of labor at ≥37 weeks gestation and a Bishop score of ≤4 were eligible. Nineteen patients received laminaria tents in addition to 4 mg PGE₂ gel, while 25 patients received PGE₂ gel alone. After 4 hr, the laminaria tents were removed and the gel was continued in both groups at 4-hr intervals. Induction with oxytocin was initiated after a Bishop score of >5 was achieved.

The groups were comparable with respect to maternal age, parity, gestational age, reason for induction, and initial Bishop score. The addition of laminaria tents to sequential PGE₂ gel did not statistically improve the time to a favorable cervix (control group 12.7 ± 8.5 hr (95% CI, 9.1–16.3) and study group 10.9 ± 7.1 hr (95% CI, 7.5–14.3) (P = 0.59). The 6-hr difference from the time of the initial PGE₂ gel placement to delivery was not detected (control group 22.4 ± 11.2 hr, 95% CI 17–27 and study group 23.4 ± 13.1 hr, 95% CI 17–29.6 (P = 0.79). The combination approach of laminaria tents and PGE₂ gel did not have a significant impact on the vaginal delivery rate, with 28.0% of patients in the control group and 26.3% of patients in the study group undergoing cesarean section (P = 0.90). Maternal and neonatal complications were rare in both groups.

We had insufficient evidence to show that the addition of laminaria tents to PGE₂ gel improved cervical ripening, the induction to delivery interval, or the cesarean section rate in patients at term undergoing induction of labor.     

经会阴B超行子宫颈成熟度评分

经会阴Ｂ超，对１００例孕３８～４２周的孕妇进行子宫颈成熟度评分。其中８６例为正常妊娠，１４例有产科合并症及并发症。胎位均为头位。阴道分娩５９例，剖宫产４１例（其中１１例未临产）。通过观察宫颈长度、官颈内口扩张程度、先露高度、宫颈回声强度和宫颈位置，参照宫颈Ｂｉｓｈｏｐ评分，建立超声宫颈成熟度评分标准。结果：评分≥９分者１４例，临产所需时间３．９±３．１小时，均临产；５～８分者５４例，临产所需时间为２０．８±３．９小时，均临产；≤４分者３２例，临产所需时间为４６．９±３．９小时，２１例临产；三者间比较，临产时间差异有极显著性（Ｐ＜０．００１）。当羊膜囊突入宫颈管内时，临产所需时间为５．３±３．７小时。提示：经会阴Ｂ超行子宫颈成熟度评分是一种简单可行的评分方法。     

Breast Stimulation for Cervical Ripening and Induction of Labour

Breast stimulation appears beneficial in relation to the number of women not in labour after 72 hours, and reduced postpartum haemorrhage rates. Breast stimulation causes the womb to contract, though the mechanism remains unclear. It may increase levels of the hormone oxytocin, which stimulates contractions. It is a non‐medical method allowing the woman greater control over the process of attempting to induce labour. The review found insufficient research to evaluate the safety of breast stimulation in a high‐risk population and until safety issues have been fully evaluated, it should not be considered for use in this group. Abstract Background: Breast stimulation has been suggested as a means of inducing labour. It is a non‐medical intervention allowing women greater control over the induction process. This is one of a series of reviews of methods of cervical ripening and labour induction using a standardised methodology. Objectives: To determine the effectiveness of breast stimulation for third trimester cervical ripening or induction of labour in comparison with placebo/no intervention or other methods of induction of labour. Search strategy: The Cochrane Pregnancy and Childbirth Group Trials Register (March 2004) and bibliographies of relevant papers. Selection criteria: Clinical trials of breast stimulation for third trimester cervical ripening or labour induction. Data collection and analysis: A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two‐stage method of data extraction. Main results: Six trials (719 women) were included. Analysis of trials comparing breast stimulation with no intervention found a significant reduction in the number of women not in labour at 72 hours (62.7% versus 93.6%, relative risk (RR) 0.67, 95% confidence interval (CI) 0.60 to 0.74). This result was not significant in women with an unfavourable cervix. A major reduction in the rate of postpartum haemorrhage was reported (0.7% versus 6%, RR 0.16, 95% CI 0.03 to 0.87). No significant difference was detected in the caesarean section rate (9% versus 10%, RR 0.90, 95% CI 0.38 to 2.12) or rates of meconium staining. There were no instances of uterine hyperstimulation. Three perinatal deaths were reported (1.8% versus 0%, RR 8.17, 95% CI 0.45 to 147.77). When comparing breast stimulation with oxytocin alone the analysis found no difference in caesarean section rates (28% versus 47%, RR 0.60, 95% CI 0.31 to 1.18). No difference was detected in the number of women not in labour after 72 hours (58.8% versus 25%, RR 2.35, 95% CI 1.00 to 5.54) or rates of meconium staining. There were four perinatal deaths (17.6% versus 5%, RR 3.53, 95% CI 0.40 to 30.88). Authors’ conclusions: Breast stimulation appears beneficial in relation to the number of women not in labour after 72 hours, and reduced postpartum haemorrhage rates. Until safety issues have been fully evaluated it should not be used in high‐risk women. Further research is required to evaluate its safety, and should seek data on postpartum haemorrhage rates, number of women not in labour at 72 hours and maternal satisfaction. *** The Cochrane Database of Systematic Reviews 2005 Issue 3. Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. This is an abstract and plain language summary of a regularly updated, systematic review prepared and maintained by The Cochrane Collaboration. The full text of the review is available in The Cochrane Library(ISSN 1464‐780X).     

去氢表雄酮硫酸盐扩张宫颈作用及毒理学研究

本文报道去氢表雄酮硫酸盐(DHA-S)促使子宫颈成熟的作用。DHA-S 可使大鼠宫颈软化和肿胀,张力降低,胶原纤维疏松,间隙增大;它还可使免子宫颈湿重增加,17β-雌二醇的血浆水平升高,DHA-S 的小鼠IV 及IP LD50(95%可信限)分别为293.3(252.32～341.0)及654.8(553.8～774.3)mg/kg。DHA-S 在微生物回复突变试验、中国仓鼠卵巢细胞培养染色体畸变试验及小鼠微核试验中,结果均为阴性。     

Cervical Ripening Induces Labour Through Interleukin 1β

Summary: In order to study the Interleukin 1β (IL-1β) levels in mechanical cervical ripening with Foley catheter, IL-1β levels in amniotic fluid of 12 women before and after cervical ripening were compared with those in 23 women in spontaneous active labour. IL-1β was present in 81.8% of patients after cervical ripening and in none prior to it. In women with spontaneous labour 69.6% had immunodetectable IL-1β. Women with spontaneous labour and those sampled after cervical ripening had similar IL-1β levels in the amniotic fluid. Cervical ripening with Foley catheter is associated with high levels of IL-1β and this probably induces labour.     

Optimal Dose of Vaginal Misoprostol for Cervical Ripening before Hysteroscopy: A Randomized Double-Blind Study

Study Objective

To evaluate the optimal dose of vaginal misoprostol (200 and 400?µg) for cervical priming before operative hysteroscopy.

Comparing Foley Catheter to Prostaglandins for Cervical Ripening in Multiparous Women

ObjectiveThis study sought to test the hypothesis that among multiparous women requiring cervical ripening, mechanical ripening with a Foley catheter is more effective than prostaglandin preparations.MethodsThis was a retrospective analysis of multiparous women with a singleton gestation who required cervical ripening in a single tertiary center from 2014 to 2019. Women who underwent cervical ripening with a Foley catheter (Foley group) were compared with women who underwent cervical ripening using a controlled-release dinoprostone vaginal insert (PGE₂-CR group) or dinoprostone vaginal gel (PGE₂-gel group). The primary outcome was the ripening-to-delivery interval.ResultsA total of 229 women met the study criteria (Foley group: 95; PGE₂-CR group: 83; PGE₂-gel group: 51). Women in the Foley group had a significantly shorter ripening-to-delivery interval compared with women in the PGE₂-CR group (16.2 ± 9.2 hours vs. 27.0 ± 14.8 hours; P < 0.001) and were more likely to deliver within 12 hours (47.4% vs. 12.0%; P < 0.001; adjusted relative risk [aRR] 3.87; 95% confidence interval [CI] 2.07–7.26) and within 24 hours (78.9% vs. 49.4%; P < 0.001; aRR 1.61; 95% CI 1.26–2.06). Women in the Foley group were also less likely to require a second ripening method compared with women in the PGE₂-CR group (1.1% vs. 8.4%; P = 0.018; aRR 7.26; 95% CI 2.99–17.62). These differences were not observed when comparing the Foley and the PGE₂-gel groups. The cesarean section rate was similar among the Foley group (9.5%), PGE₂-CR group (9.6%; P = 0.970), and PGE₂-gel group (11.8%; P = 0.664).ConclusionIn multiparous women requiring cervical ripening, all methods of cervical ripening have a similar success rate. However, the use of a PGE₂-CR insert is associated with a considerably longer interval to delivery compared with a Foley catheter or PGE₂ gel.     

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal–fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.     

A Randomized Controlled Trial of Extra-amniotic Ethinyloestradiol for Cervical Ripening in Multiparas

A double-blind randomized controlled trial was carried out to determine if ethinyloestradiol applied extra-amniotically would ripen the unfavourable cervix at term. Twenty five multiparas were given 150 mg ethinyloestradiol gel while 25 multiparas were given gel alone. There was no difference between the ethinyloestradiol and control groups in either mean change of Bishop score or the induction-to-delivery interval.     

An Evaluation of Cervical Smears Consisting of Spatula and Cytobrush Samples

Analysis of 100 paired spatula and Cytobrush cervical smear samples taken and evaluated by one person showed that the combined smear was excellent for sampling the transformation zone and for detecting lesions. However, care in obtaining and evaluating smears are still vital if false-negative smears are to be eliminated. The greater use of the 2-sample smear is advocated.     

Dinoprostone Compared With Misoprostol for Cervical Ripening for Induction of Labor at Term

H.L. is a 25‐year‐old woman, gravida 2 para 1‐0‐0‐0 admitted to the birth unit at 38 and 6/7 weeks' gestation for induction of labor because of an obstetric history of a previous intrauterine fetal demise (IUFD) at term. The previous pregnancy occurred 5 years before this pregnancy, and the etiology of the IUFD was not determined. The current pregnancy was uncomplicated. Maternal serum alpha‐fetoprotein and gestational diabetes screening were normal. Serial sonograms and the biweekly nonstress tests (NST) that were first performed at 32 weeks' gestation showed no abnormalities. The cervical examination on admission was 1 cm dilated, 50% effaced, medium consistency and posterior, ?3 station, vertex presentation, equivalent to a Bishop score of 3, with membranes intact. The NST conducted on admission was reactive and she had no significant uterine activity. After informed consent and consultation between the midwife and attending obstetrician, the plan to administer 25 mcg of misoprostol (Cytotec) per vagina, every 4 hours, for up to 6 doses, was initiated. H.L. began feeling mild contractions after receiving her third dose of misoprostol; however, her cervical examination remained unchanged. A routine change in the inpatient obstetric providers resulted in a change from continued vaginal misoprostol to use of vaginal 10 mg dinoprostone (Cervidil) for cervical ripening. This change in medical induction agents was based on the belief and experience of the incoming midwife that dinoprostone is a better ripening agent, and the fact that there had been no cervical change after 3 doses of misoprostol. Two hours after insertion of the dinoprostone, H.L. had a period of tachysystole. The dinoprostone was removed from the vagina, oxygen via face mask was started, and 0.25 mg of terbutaline was given subcutaneously. After 6 hours of rest and observation, the cervical examination was 2 cm dilated, 70% effaced, ?2 station. An oxytocin infusion was started at 1 milliunit per minute, and was increased to a maximum of 2 milliunits per minute with adequate uterine contractions. After 2 more hours, H.L.'s cervical examination was 2 to 3 cm dilated, 70% effaced, ?1 station, with bulging membranes. Membranes were artificially ruptured at this time, and the fluid was noted to be clear. After an hour and a half of intense, frequent contractions, H.L. requested an epidural. A cervical examination revealed labor had progressed to 6 to 7 cm, 100% effaced, and 0 station. Twenty minutes later—coincidentally, the same time as the arrival of the anesthesiologist—H.L. sat up and began spontaneous pushing efforts. She was examined and found to be fully dilated. Following a 6‐minute second stage of labor, a 7 lb, 2 oz male was born spontaneously and without difficulty, with a loose nuchal cord, and Apgar scores of 9 and 9, at 1 and 5 minutes, respectively. The placenta was delivered spontaneously and grossly intact after a 7‐minute third stage of labor. There were no lacerations or excessive uterine bleeding. The postpartum and neonatal periods progressed well.     

宫腔操作前米索前列醇不同给药途径对宫颈成熟影响的Meta分析

目的:评价宫腔操作前米索前列醇通过不同给药途径促宫颈成熟的作用效果及不良反应。方法:计算机检索Medline、Embase、The Cochrane Library、中国知网(CNKI)、中国生物医学文献数据库(CBM)、万方数据库,时限为自建库至2014年10月。由2名研究者按照纳入标准与排除标准独立筛选文献、提取资料和评价文献质量后,采用Rev Man5.2软件进行Meta分析。结果:共纳入12篇文献,共2 529例患者。Meta分析结果显示,口服、舌下含服和阴道给药3种给药方式两两比较均提示其宫颈宽度的差异无统计学意义(均P0.05);阴道给药后宫腔操作用时少于口服给药(P0.05),但扩张宫颈耗时差异无统计学意义(P0.05);舌下含服后扩张宫颈耗时和宫腔操作用时均少于阴道给药(均P0.05)。在药物相关不良反应方面,口服及舌下含服米索前列醇后腹泻与恶心发生率明显高于阴道给药(均P0.05),舌下给药后呕吐发生率明显高于阴道给药(P0.000 1);此外,各种给药途径子宫痉挛收缩、阴道出血、发热、寒颤等不良反应的发生率比较差异无统计学意义(P0.05)。结论:口服、舌下含服和阴道给药3种给药途径在促宫颈成熟方面无差异;考虑避免药物相关不良反应,建议在宫腔操作前采取阴道给予米索前列醇。     

An Evaluation Of Teaching Cervical Mucus Symptoms To Ovulating Infertile Women

Women (n = 113) with ovulatory menstrual cycles but complaining of infertility were instructed in the observation and charting of cervical mucus symptoms. At the completion of 3 teaching cycles, 80 subjects (70.8%) had successfully charted at least one cycle with an ovulatory mucus pattern (10 subjects became pregnant). Sixty-two (54.9%) of the women continued for a further 3 cycles of investigation during which, around the time of ovulation, an assessment was made of the mucus at the cervix. On the basis of this assessment subjects were classified as either Group 1: charting ovulatory mucus symptoms with 'fertile type' mucus observed at the cervix - 48 subjects (10 became pregnant); Group 2A: charting uninterpretable mucus symptoms but 'fertile type' mucus observed at the cervix - 8 subjects; or, Group 2B: charting uninterpretable mucus symptoms and mucus of poor quality observed at the cervix - 6 subjects. The study shows that infertile ovulating women can be taught to observe and chart their mucus symptoms. Such charting is useful in identifying the fertile period of the cycle for timing of intercourse and for timing of postcoital tests and cervical assessment. It is also useful in identifying the small number of women (5.3%) with an apparent deficiency in mucus production. Whether the 20 subjects (17.7%) who became pregnant were assisted in this objective by their charting of symptoms is unclear.     

Retrospective Comparison of PGE2 Vaginal Insert and Foley Catheter for Outpatient Cervical Ripening

ObjectiveTo compare the efficacy of two methods of outpatient cervical ripening (CR): an intracervical Foley catheter and a prostaglandin E₂ (PGE)₂ slow-release vaginal insert.MethodsAll records of women receiving outpatient CR at a tertiary care hospital from January 2017 to June 2018 were retrospectively reviewed. We compared time from insertion of first CR agent until delivery between groups using a Cox proportional hazards (CPH) model. Exclusion criteria included age <18 years, multiple gestation, or contraindication to either CR method. Secondary outcomes included time from removal of agent and time from admission until delivery, additional CR used, uterine tachysystole, labour and delivery complications, type of delivery, and adverse neonatal outcomes.ResultsA total of 153 patients were included (82 Foley; 71 PGE₂). Baseline characteristics were comparable except for lower dilation in the PGE₂ group (16% vs. 38% <1cm dilated; P < 0.05). In the CPH model, time from insertion to delivery was not different between PGE₂ and Foley catheter groups (median 27 vs. 33 h), controlling for parity, gestational age, initial dilation, and use of oxytocin (HR 1.13, 95% confidence interval 0.77–1.68). Patients in the PGE₂ group were more likely to experience uterine tachysystole (9% vs. 0%; P < 0.01) and require another method of CR (34% vs. 1%; P < 0.001). There were no differences in neonatal or maternal adverse outcomes between groups.ConclusionOur results suggest that outpatient Foley catheter and PGE₂ CR are comparable in time from insertion to delivery; however, PGE₂ inserts are associated with higher rates of tachysystole and the need for second CR method. A prospective study is warranted to further investigate these findings.     

米索前列醇用于足月妊娠引产的临床观察

目的：探讨米索前列醇用于足月妊娠引产的安全性及效果。方法：将６０例有引产指征的孕足月单胎头位、无宫缩的初产妇，随机分成两组，研究组（３０例）用米索前列醇５０μｇ阴道用药，每３小时１次至正式临产；对照组（３０例）用蓖麻油鸡蛋餐口服。结果：两组引产总有效率无显著差异，研究组引产时间显著少于对照组（Ｐ＜０．０５），研究组需静脉滴注催产素人数为１０．０％，显著少于对照组的４０．０％，（Ｐ＜０．０５），用药６小时后研究组宫颈评分提高５．５分，对照组提高３．１分，评分结果比较，差异有显著性（Ｐ＜０．０５），研究组子宫收缩过频的发生率为１６．７％，对照组为３．０％。结论：阴道放置米索前列醇用于足月妊娠引产能促宫颈成熟及发动子宫收缩，是安全、有效的引产方法     

The Cervical Cap: An Alternative Contraceptive

Recent findings on health hazards of oral contraceptives and intrauterine devices have prompted American women to seek alternative forms of birth control which are both safe and effective. The cervical cap may provide a desired alternative and is relatively inexpensive. Types of caps are described below, with nursing guidelines for use and fitting.