Low-dose vaginal misoprostol with or without Foley catheter for late second-trimester pregnancy termination in women with previous multiple cesarean sections

Purpose: To compare between low dose vaginal misoprostol with and without Foley catheter for late second trimester pregnancy termination in women with previous multiple cesarean sections.

Materials and methods: A prospective randomized controlled clinical trial, patients were randomly allocated to either low dose vaginal misoprostol group (n?=?40) or combined low dose vaginal misoprostol plus Foley catheter group (n?=?38). The primary outcome was complete abortion. Secondary outcomes were induction-to-abortion interval, the number of misoprostol doses and occurrence of complications.

Results: Incomplete abortion rate was significantly lower in combined group than misoprostol only group (2.6%versus 15% respectively, p?=?.03). Induction-to-expulsion interval with the combined vaginal misoprostol plus Foley catheter was significantly shorter (p?=?.01) and the number of misoprostol doses in the combined group was significantly lower (p?=?.04). No statistically significant difference in the frequency of complications between both groups.

Conclusions: The combination of low dose vaginal misoprostol and Foley catheter is an effective and safe method for termination of second trimester pregnancy in women with previous multiple cesarean sections.     

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.     

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 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.     

Pre-induction cervical ripening: comparing between two vaginal preparations of dinoprostone in women with an unfavorable cervix

Abstract

Objective: Prostaglandin E2 (PGE2-Dinoprostone) is accepted for both ripening of the cervix and induction of labor. As conflicting data exist concerning the efficiency and safety of different treatment modalities, we aimed to compare slow-release vaginal insert PGE2 with serial vaginal tablets of PGE2 for cervical ripening and induction of labor.

Methods: A retrospective cohort study comparing all pregnancies who underwent induction of labor by either a single slow-release vaginal insert of 10?mg PGE2 (study group) to a historical control group of women who were treated with serial administration of 3?mg vaginal PGE2 tablets in a 2:1 ratio, matched by parity.

Results: Overall, 639 women were enrolled (213 treated with PGE2 tablets and 426 with slow-release vaginal inserts). Vaginal insert was associated with shorter initiation-to-ripening interval (12.4?±?7.7 versus 18.6?±?15.2?h, p?<?0.001) and a higher rate of delivery within 24?h (61.5 versus 51.6%, p?=?0.018). Vaginal insert was associated with an increased rate of tachysystole (8.0 versus 3.1%, p?<?0.01); however, the rates of cesarean section or operative delivery due to non-reassuring fetal heart rate (NRFHR) were similar. On multivariable analysis, slow-release vaginal insert was independently associated with a higher rate of delivery within 24?h (OR 1.50, 95% CI 1.04–2.18).

Conclusion: Slow-release PGE2 vaginal insert achieves cervical ripening and subsequently delivery over a shorter time period than PGE2 tablets, without increasing uterine hyperstimulation rate.     

Oral versus vaginal prostaglandin for labor induction

Objective: To compare the efficacy and safety of oral prostaglandin (PG) in solution versus vaginal PG gel for labor induction.

Design: A retrospective study.

Methods: Data from original obstetric records at a university hospital in Sweden 2012–2013.

Results: In all women, oral PG resulted in vaginal birth (VB)?p?p?=?0.02). In primiparous women, oral PG was followed by VB <24?h in 54% compared to 71% (p?=?0.01), and CS in 25% versus 41% (p?=?0.03). In women with an unripe cervix, oral PG lead to VB <24?h in 66% compared to 79% (p?=?0.01), and CS in 21% versus 33% (p?=?0.04). Despite a longer induction to vaginal delivery interval with oral PG, the rates of obstetric bleeding, chorioamnionitis, and neonatal asphyxia were not increased.

Conclusions: Oral PG in solution was less effective than vaginal PG gel in achieving VB <24?h. However, oral PG was safer, since it resulted in fewer CSs without increasing maternal morbidity or neonatal asphyxia.     

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.)     

A randomized clinical trial comparing vaginal misoprostol versus cervical Foley plus oral misoprostol for cervical ripening and labor induction

We compared labor induced by vaginal misoprostol versus a supracervical Foley catheter and oral misoprostol. Singleton pregnancies at > or = 24 weeks' gestation were randomized to either an initial 25-microg dose of intravaginal misoprostol, followed by 50-microg intravaginal doses at 3- to 6-hour intervals, or a supracervical Foley balloon and 100 microg of oral misoprostol at 4- to 6-hour intervals. Primary outcome was time from induction to delivery. One hundred twenty-six women were randomized to vaginal misoprostol alone (group I) and 106 women to Foley and oral misoprostol (group II). The groups were similar in age, weight, gestational age, parity, indication for induction of labor, and oxytocin use. Cesarean delivery rates at 37% and cesarean indications were similar ( P = 0.25). The time from induction to delivery in group II (12.9 hours) was significantly shorter than that in group I (17.8 hours, P < 0.001). Uterine tachysystole occurred less often in the vaginal misoprostol group (21% versus 39%, P = 0.015). Compared with vaginal misoprostol, delivery within 24 hours was significantly more likely with a Foley balloon and oral misoprostol. The use of terbutaline and peripartum outcomes were similar in the two groups.     

Induction of labor in women with a uterine scar

Objective: To evaluate the frequency of uterine rupture following induction of labor in women with a previous cesarean section. Misoprostol was compared to other methods of induction.

Methods: A retrospective cohort study of 208 women attempting induction of labor after one previous cesarean section. Delivery data were collected retrospectively and compared. Group 1(2009–2010) was compared with Group 2 (2012–2013). In Group 1, the main method of induction was vaginal PGE₂ (prostaglandin-E₂), amniotomy, oxytocin or a balloon catheter. In Group 2, the dominant method of induction was an oral solution of misoprostol. Main outcome measures: frequency of uterine rupture in the two groups.

Results: Nine cases (4.3%) of uterine rupture occurred. There was no significant difference in the frequency of uterine rupture following the change of method of induction from PGE₂, amniotomy, oxytocin or mechanical dilatation with a balloon catheter to orally administered misoprostol (4.1 versus 4.6%, p?=?0.9). All ruptures occurred in women with no prior vaginal delivery.

Conclusion: The shift to oral misoprostol as the primary method of induction in women with a previous cesarean section did not increase the frequency of uterine rupture in the cohort studied.     

The effect of vaginal pH on labor induction with vaginal misoprostol

Objective.?To estimate the association of vaginal pH on the induction to vaginal delivery interval in labor induction with vaginal misoprostol.

Methods.?Women presenting at term with intact membranes for labor induction were recruited. The pH of the vagina was measured during a digital examination of the cervix to determine the Bishop Score. Labor was induced with 25?μg of vaginal misoprostol placed every 6?h until spontaneous rupture of membranes or active labor occurred. The primary outcome was the induction to vaginal delivery interval in the lower pH (?<?5) versus higher pH (???5) group. Secondary outcomes assessed maternal and neonatal morbidities. Sample size calculated a priori estimated 120 subjects were required for a power of 95% and a 2-tailed α of 0.05.

Results.?120 women met inclusion criteria and had available pH data. There was no difference in the induction to vaginal delivery interval in the lower pH (1455?min) versus higher pH group (1295 minutes, Mean difference 160[?147,468] P?=. 30). No difference was observed for operative delivery rates or neonatal outcomes.

Conclusion.?The pH of the vagina may not affect the length of the induction to vaginal delivery interval in women undergoing labor induction with vaginal misoprostol. Further research is required to determine factors that may influence the efficacy of vaginal misoprostol when used for labor induction.     

Comparison of intravaginal misoprostol and intracervical Foley catheter alone or in combination for termination of second trimester pregnancy

Objectives: To examine the effectiveness, safety and acceptability of intravaginal misoprostol and intracervical Foley catheter alone or in combination for termination of second trimester pregnancy.

Methods: This clinical study was conducted on 90 pregnant patients intended for termination of pregnancy between 13 and 24 gestational weeks for any indication. Enrolled women are equally allocated into three groups:

??Group I (Misoprostol group): a standard regimen of moistened misoprostol (400?μg) 4 hourly inserted vaginally.

??Group II (Catheter group): intracervical Foley catheter inserted, inflated and placed on traction.

??Group III (Combined group): intracervical Foley catheter inserted with a standard regimen of moistened misoprostol (400?μg) 4 hourly intravaginally was used.

Procedure efficacy (defined as complete abortion performed on site), safety and acceptability were assessed.

Results: The induction to abortion interval was 7.5?±?1.25?h in the combined group, compared to 11.76?±?1.63?h in the misoprostol group and 19.76?±?1.52?h in the catheter group (p value?Conclusions: The present results confirmed the high success rate with the shortest induction to abortion interval with a combined use of intracervical Foley catheter and misoprostol for termination of second trimester pregnancy.     

Pregnancy outcomes after failed cervical ripening with prostaglandin E2 followed by Foley balloon catheter

Objective: To study pregnancy outcomes of cervical ripening with Foley catheter, in women who failed to respond to prostaglandin-E2 (PGE2).

Methods: A retrospective cohort study of all patients with a singleton pregnancy, who underwent cervical ripening with vaginal PGE2, between 2013 and 2014, was performed. Patients who failed to respond to a total dose of 6–9 mg PGE2, defined as no change in Bishop score, underwent subsequent ripening with Foley catheter (non-responders group). Data were compared to patients who achieved sufficient response to a total dose of up to 9 mg PGE2 (responders group).

Results: Compared with the responders group (n?=?813), patients in the non-responders group (n?=?49) had higher rates of nulliparity (p?<?0.001), pre-induction cervical dilation ≤1?cm (p?=?0.004), pre-induction cervical effacement?≤50% (p?=?0.01) and birth weight >4000?g (p?=?0.02). A significantly higher cesarean delivery rate was observed in the non-responders group (51 versus 12.3%, p?<?0.001). Failed ripening with PGE2 was found to be independently associated with cesarean delivery (aOR?=?5.11, 95% CI?=?2.72–9.62).

Conclusions: The need for an additional cervical ripening method after failure with PGE2 is associated with a very high risk of cesarean delivery. This is particularly significant in nulliparous women, women carrying large fetuses, and women presenting with a low Bishop score.     

Uterine packing versus Foley’s catheter for the treatment of postpartum hemorrhage secondary to bleeding tendency in low-resource setting: A four-year observational study

Objective: To assess the effectiveness and safety of uterine packing versus Foley’s catheter tamponade for controlling postpartum hemorrhage (PPH) secondary to bleeding tendency after vaginal delivery.

Methods: This was a prospective observational study conducted on 92 patients with primary PPH due to bleeding tendency following vaginal delivery who were unresponsive to uterotonics and bimanual compression of the uterus. Patients were divided into two groups, Uterine packing group (n?=?45) and Foley catheter group (n?=?47). The primary outcome was the success rate of the procedure. Secondary outcome addressed the maternal complications.

Results: The use of uterine packing resulted in stoppage of active bleeding in 93.3% of cases compared to only 68.1% in the Foley’s catheter group (p?p?>?0.05). Six cases who failed to Foley catheter tamponade underwent emergency hysterectomy with no cases in the uterine packing group.

Conclusions: The use of uterine packing to arrest PPH is simple, quick and safe procedure to avoid further surgical interventions and to preserve the fertility in low-resource setting.     

Planned vaginal delivery versus planned cesarean delivery in cases of low-lying placenta

Objective: To assess the applicability of trial of labor in cases of low-lying placenta.

Methods: In this observational cohort study, we collected data from the women with low-lying placenta delivered at our hospital between April 2012 and December 2015. Low-lying placenta was diagnosed when the length from the placental lowest edge to the internal cervical os (placenta-os distance) was 0–20?mm at 36 gestational weeks. Planned mode of delivery for each case was determined by patient’s preference. Maternal and neonatal outcomes were compared between the planned vaginal delivery group (N?=?11) and the planned cesarean delivery group (N?=?7).

Results: All the women in the planned cesarean delivery group underwent scheduled cesarean section at 37–38 gestational weeks. Three cases in the planned vaginal delivery group required emergency cesarean section for uncontrollable antepartum bleeding. The intrapartum blood loss was significantly smaller in the planned vaginal delivery group than in the planned cesarean delivery group (946?±?204?g vs. 1649?±?256?g, p?=?0.047). Umbilical arterial blood pH was similar between the two groups. All the women requiring emergency cesarean section were accompanied by marginal sinus.

Conclusions: Trial of labor can be offered to all the women with low-lying placenta except for those accompanied by marginal sinus.     

Frequent low-dose misoprostol for termination of second-trimester pregnancy

Objectives?To determine the efficacy of an application regimen of low-dose frequent misoprostol for second-trimester pregnancy termination.

Methods?A total of 250 women between 12 and 20 weeks of gestation who were scheduled for second-trimester pregnancy termination received 200?μg vaginal misoprostol followed by 100?μg oral misoprostol every 2?h until expulsion of the fetus. Mechanical cervical dilatation with a 16-French Foley balloon catheter was performed if no cervical dilatation was observed after 24?h. The main outcome measures were the delivery rate within 24?h and the factors influencing the interval between the onset of induction and abortion. Secondary outcome measures were the side-effects of the regimen and the total misoprostol dose required.

Results?With application of this protocol, 245 women (98%) delivered within 24?h of induction. The mean (± standard deviation) misoprostol dose used was 728?±?297?μg (200–2100?μg). Cox regression analysis revealed that vaginal spotting or nulliparity do not effect the induction–abortion time. On the other hand, using this regimen induction to abortion time tends to be longer in the presence of live fetuses (odds ratio (OR)?=?0.45; confidence interval (CI)?=?0.2–0.8; p?=?0.008) and pregnancies with gestational age >?16 weeks (OR?=?0.59; CI?=?0.4–0.8; p?=?0.003) when compared with cases of in utero death and pregnancies with a gestational age of 12–13 weeks, respectively. Twenty-seven women (10.8%) experienced one or more side-effects attributable to misoprostol.

Conclusion?The 100-μg oral misoprostol every 2?h following 200?μg vaginal misoprostol is a highly effective protocol for inducing abortion at 12–20 weeks of pregnancy. Cases with live fetuses or pregnancies with older gestational age (>?16 weeks) deliver in a longer time period.     

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.

     

Addition of isosorbide mononitrate to misoprostol for cervical ripening in post-term pregnancy: A randomized controlled trial

ObjectiveThe purpose of this paper is to compare the effect of vaginal isosorbide mononitrate added to misoprostol versus misoprostol alone in cervical ripening and labor induction in post-term pregnancy.MethodsIn this double-blind controlled trial study, 150 pregnant women in post-term pregnancy who were candidates for labor induction were selected. The participants were assigned randomly to receive either vaginal isosorbide mononitrate (IMN) (40 mg) or placebo. Misoprostol (25 mg) was added to both groups as needed. Time to full cervical ripening, time to delivery, and the amount of misoprostol used in each group were assessed.ResultsThe time interval from the administration of IMN to full cervical ripening was shown to be significantly lower in the IMN+ misoprostol groups versus the comparison group (p = .032). The adjusted analysis of this time interval after controlling for age, BMI, gravidity, and Bishop score on administration remained significantly less (p = .045),the mean difference being ?4.85 h, CI 95% ?9.58 to ?.12. Isosorbide treatment resulted in significantly less misoprostol used versus misoprostol alone (2.37 ± 1.02 versus 3.08 ± 1.29), adjusted p-value = .001, CI 95% ?1.09 to ?.32. We found no significant increase in maternal–fetal outcomes or side effects of the IMN+ misoprostol group compared with the misoprostol group.ConclusionThis study found that intravaginal IMN added to misoprostol is more effective in reducing time to full cervical ripening versus misoprostol alone in post-term pregnancy. It also reduces the need for more misoprostol.     

Second dose of PGE2 vaginal insert versus Foley transcervical balloon for induction of labor after failure of cervical ripening with PGE2 vaginal insert

Purpose: To determine the success rate of induction of labor (IOL) using Foley transcervical balloon (FTB) versus prostaglandin E₂ (PGE₂) vaginal insert, following failure of cervical ripening with PGE₂ vaginal insert.

Materials and methods: A retrospective cohort study of all pregnant women admitted for IOL with either FTB or PGE₂ vaginal insert. Either second dose of PGE₂ vaginal insert or FTB was used as a second line treatment after failure (not giving birth in 24?h from insertion) of first PGE₂ vaginal insert.

Results: During the study period, 1162 women were admitted for IOL. Failure was reported in 322/852 (37.8%) in the FTB versus 162/310 (52.2%) in the PGE₂ group (p?2 as first line who did not deliver after 24?h, 14 had spontaneous rupture of membranes, 15 underwent stripping and 42 were in still in active labor. The remainder were allocated to either second trial of PGE₂ treatment (n?=?58) or FTB (n?=?33) with failure rate higher in the PGE₂ group, not statistically significant (p?=?0.23).

Conclusion: IOL with FTB was not superior to PGE₂ vaginal insert for IOL following failure of cervical ripening with PGE₂ vaginal insert.     

Induction of labor in twin gestation: lessons from a population based study

Introduction: The route of delivery and the role of induction of labor in twin gestations are controversial. The aim of this study was to determine the efficacy of induction of labor in twin gestations.

Methods: This retrospective population based cohort study included 4605 twin gestations divided into following groups: 1) spontaneous parturition (n?=?2937, 63.78%); 2) induction of labor (n?=?653, 14.2%) and 3) elective cesarean delivery (n?=?1015, 22.04%).

Results: The rate of vaginal delivery in the labor induction group was 81% (529/653). In comparison to the other study groups, induction of labor in twins was independently associated with a 77% reduction in the risk of cesarean delivery (OR 0.23; 95% CI 0.18–0.31) and a 78% reduction in the risk of postpartum death for the second twin (OR 0.22; 95% CI 0.05–0.94). The rate of nulliparity, term delivery and labor dystocia was higher in the induction of labor group (p?<?0.001 in all comparisons).

Conclusions: Our results suggest that induction of labor in twin gestation is successful and is independently associated with substantial reduction in the risk of cesarean delivery and postpartum death of the second twin.     

The effect of vaginal pH on the efficacy of vaginal misoprostol for induction of labor

BACKGROUND: Misoprostol was reported to be an effective agent for cervical ripening and induction of labor. Our purpose was to evaluate whether vaginal pH affected the efficacy of misoprostol for induction of labor. METHODS: The vaginal pH of 103 women admitted for induction of labor were measured. According to the vaginal pH, two groups were generated, those with a vaginal pH <5 (n= 65), and those with a vaginal pH > or =5 (n=38). All women received intravaginal misoprostol tablets, 50 microg every 4 hours up to three doses. Further medication was not given after entry into active labor or spontaneous rupture of membranes. In cases of failed induction or arrest disorders oxytocin augmentation was used. RESULTS: The average interval from start of induction to vaginal delivery was shorter, and oxytocin augmentation was required less commonly in the lower pH group. We did not find any significant difference in cesarean section rates, or incidence of adverse maternal or fetal outcome. CONCLUSION: Vaginal pH may affect the pharmacokinetics of vaginally administered misoprostol, and may cause an alteration in induction to delivery interval.