Premature rupture of membranes near term: induction of labor with endocervical prostaglandin E2 gel or intravenous oxytocin

We have studied the influence of endocervical application of 0.4 mg prostaglandin E2 (PGE2) in gel on the clinical outcome of pregnancies of at least 36 weeks' duration complicated with premature rupture of the membranes (PROM) and unripe cervix, (modified Bishop score of 7 or less). There were 579 women in the study. The PGE2 gel was applied within the first 12 hours after PROM. The first 60 women were randomly divided into controls given oxytocin infusions and experimental subjects given PGE2 gel. All others were given PGE2 gel, and the results were compared with those obtained in patients with similar criteria who were treated with oxytocin infusions during the preceding year. The clinical outcome was significantly better in the PGE2-treated patients than oxytocin-infused patients. PROM to delivery interval and the incidence of operative deliveries were significantly reduced. No adverse effects on the neonates were observed and the incidence of neonatal infection declined. It is concluded that cervical ripening with PGE2 gel in patients with PROM and unripe cervix near term significantly improves the outcome for both mother and child.     

欣普贝生用于足月胎膜早破低宫颈评分引产的效果观察

目的:探讨欣普贝生(地诺前列酮栓)在足月胎膜早破初产孕妇中应用的安全性及有效性。方法:100例足月胎膜早破单胎孕妇,破膜2h后未临产,宫颈条件未成熟(宫颈Bishop评分≤4分),孕妇知情同意后欣普贝生组入组50例,催产素组50例。比较两组的分娩方式及母儿结局情况。结果:与催产素组比较,欣普贝生组8h、12h促宫颈成熟总有效率明显增加(92.0%vs 64.5%,P0.01;95.9%vs 79.2%,P0.05)。欣普贝生组阴道分娩率明显升高(86.0%vs 60.0%,P0.01),且欣普贝生组用药12h、24h内阴道分娩率亦显著提高(42.0%vs 8.0%,P0.001;64.0%vs 34.0%,P0.01)。欣普贝生组用药至临产、用药至阴道分娩时间明显短于催产素组[(7.4±1.0)h vs(14.2±2.0)h,P0.01;(15.4±1.4)h vs(21.4±1.6)h,P0.01]。欣普贝生组引产失败率、绒毛膜羊膜炎发生率显著降低(2.0%vs 16.0%,P0.05;0 vs 12.0%,P0.05);两组急产、胎儿宫内窘迫、相对性头盆不称发生率无明显统计学差异;两组均无产后出血、新生儿窒息。结论:足月胎膜早破且宫颈条件未成熟的初产孕妇,应用欣普贝生促宫颈成熟安全、有效,且效果优于直接催产素引产,但用药期间应加强母儿监护。     

Influence of misoprostol or prostaglandin E(2) for induction of labor on the incidence of pathological CTG tracing: a randomized trial

OBJECTIVE: To compare the efficacy and safety of misoprostol (prostaglandin E(1) (PGE(1))) with dinoprostone (prostaglandin E(2) (PGE(2))) for third trimester cervical ripening and labor induction. STUDY DESIGN: Patients requiring induction of labor were randomly assigned to receive either 50 microg of intravaginal misoprostol every 4 h or 0.5 mg of intracervical dinoprostone gel every 6 h. Eligibility criteria included gestation = 36 weeks. Primary outcome was the time interval from induction to delivery; secondary outcomes were mode of delivery, perinatal outcome, and interpretation of cardiotocogram (CTG) records. RESULTS: Two hundred women were randomly enrolled to receive either misoprostol (n = 100) or dinoprostone (n = 100). Time induction-to-delivery at 12, 24 and 48 h and the need for oxytocin were reduced with misoprostol (P < 0.05). Pathological CTG tracing according to FIGO and Melchior scores were more frequent in the misoprostol-treated group (P < 0.001). CONCLUSION: Misoprostol shortened the induction-to-delivery interval, but is associated with a higher incidence of abnormal CTG than prostaglandin E(2).     

Cervical priming and labor induction with vaginal application of 3 mg PGE2 in suppositories in term pregnant women with premature rupture of amniotic membranes and unfavorable cervix

Sixty-one term pregnant women, 29 nulliparous (Group A) and 32 multiparous (Group B) with unfavorable cervix and premature rupture of the membranes (PROM) were given 3 mg PGE2 in suppository form for cervical ripening and labor induction. Five hours after starting the treatment, 12 women of the 29 in Group A and 21 of the 31 in Group B had a favorable cervix and established labor. The remaining 17 nulliparae and 11 multiparae still had an unfavorable cervix and were then given another PGE2 suppository. Until the next morning, i.e. within 24 h, 19 nulliparous and 22 multiparous women gave birth whereas a further 5 nulliparous women who now had favorable cervix but no uterine contractions were delivered after stimulation with intravenous oxytocin. The remaining undelivered women were given another PGE2 suppository. With or without additional oxytocin stimulation, all but 2 multiparous women could be delivered within a further 12 hours. The total number of instrumental deliveries in Group A was 2 caesarean sections due to disproportion (7%) and 5 ventouses. In Group B, 3 caesarean sections (9%) had to be carried out, one due to fetal distress and 2 due to failed induction. From the results of this study we conclude that vaginal application of 3 mg PGE2 in suppository form can be used to induce labor in patients with PROM and unripe cervix. However, when the results are compared with those obtained in previous studies after application of PGE2 in gel, the latter technique seems preferable.     

Uterine rupture during induced or augmented labor in gravid women with one prior cesarean delivery.

OBJECTIVE: Our purpose was to examine the risk of uterine rupture during induction or augmentation of labor in gravid women with 1 prior cesarean delivery. STUDY DESIGN: The medical records of all gravid women with history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. The current analysis was limited to women at term with 1 prior cesarean delivery and no other deliveries. The rate of uterine rupture in gravid women within that group undergoing induction was compared with that in spontaneously laboring women. The association of oxytocin induction, oxytocin augmentation, and use of prostaglandin E(2) gel with uterine rupture was determined. Logistic regression analysis was used to examine these associations, with control for confounding factors. RESULTS: Of 2774 women in the analysis, 2214 had spontaneous onset of labor and 560 women had labor induced with oxytocin or prostaglandin E(2) gel. The overall rate of rupture among all patients with induction of labor was 2.3%, in comparison with 0.7% among women with spontaneous labor (P =.001). Among 1072 patients receiving oxytocin augmentation, the rate of uterine rupture was 1.0%, in comparison with 0.4% in nonaugmented, spontaneously laboring patients (P =.1). In a logistic regression model with control for birth weight, use of epidural, duration of labor, maternal age, year of delivery, and years since last birth, induction with oxytocin was associated with a 4.6-fold increased risk of uterine rupture compared with no oxytocin use (95% confidence interval, 1.5-14.1). In that model, augmentation with oxytocin was associated with an odds ratio of 2.3 (95% confidence interval, 0.8-7.0), and use of prostaglandin E(2) gel was associated with an odds ratio of 3.2 (95% confidence interval, 0.9-10.9). These differences were not statistically significant. CONCLUSION: Induction of labor with oxytocin is associated with an increased rate of uterine rupture in gravid women with 1 prior uterine scar in comparison with the rate in spontaneously laboring women. Although the rate of uterine rupture was not statistically increased during oxytocin augmentation, use of oxytocin in such cases should proceed with caution.     

Induction of labour with a favourable cervix and/or pre-labour rupture of membranes

Premature rupture of membranes (PROM) occurs in 8% of term deliveries. In this situation labour induction with prostaglandins, compared with expectant management, results in a reduced risk of chorioamnionitis, neonatal antibiotic therapy, neonatal intensive care (NICU) admission, and increased maternal satisfaction. The use of prostaglandin is associated with an increased rate of diarrhoea and use of analgesia/anaesthesia. Compared with oxytocin, prostaglandin induction results in a lower rate of epidural use and internal fetal heart rate monitoring but a greater risk of chorioamnionitis, nausea, vomiting, more vaginal examinations, neonatal antibiotic therapy, NICU admission and neonatal infection. Women should be informed of the risks and benefits of each method of induction.Misoprostol is gaining increasing interest as an alternative induction agent. It appears to be an effective method of labour induction with term PROM. Further research is needed to identify the preferred dosage, route and interval of administration, and to assess uncommon maternal and neonatal outcomes.There has been limited research on the use of prostaglandins, including misoprostol, for induction of labour with a favourable cervix and intact membranes. Compared with intravenous oxytocin (with and without amniotomy), labour induction using vaginal prostaglandins in women with a favourable cervix (with and without PROM) results in a higher rate of vaginal delivery within 24 hours and increased maternal satisfaction. In women with a favourable cervix, artificial rupture of membranes followed by oral misoprostol has similar time to vaginal delivery compared with artificial rupture of membranes followed by oxytocin. Further research with prostaglandins, including misoprostol, is needed to evaluate other maternal and neonatal outcomes in women being induced with a favourable cervix.No form of prostaglandin induction in women with PROM or favourable cervix has proven clearly superior to oxytocin infusion.     

Ripening of the uterine cervix and induction of labour at term with prostaglandin E2 in viscous gel.

In order to achieve ripening of the uterine cervix or induce labour in patients at term with an unfavourable cervical state, 1 mg of prostaglandin E2 (PGE2), suspended in a viscous gel, was instilled into the cervical canal. In a pilot study, 41 patients received the PGE2-gel. Twenty-three of these, (56%), went into labour, and delivery occurred without further stimulation within 15 hours. In the remaining 18 patients, there was a marked improvement of the cervical state, which changed from an average (modified) Bishop score of 2.5 to 6.1 within 24 hours. In a double-blind study comprising 20 nulliparae, 10 received gel containing PGE2 and 10 gel without prostaglandin. Cervical state did not change significantly (Bishop score 3.6 and 4.0) after 24 hours in patients receiving placebo gel. In those receiving PGE2 gel, 8 went into labour and were delivered without further induction within 13 hours. Two patients showed an increase in Bishop score from 3 to 6 and 7, respectively, after 24 hours. They were then induced by oxytocin and delivery occurred after 8 and 10 hours. The results suggest that administration of PGE2 intracervically can induce ripening of the cervix in patients at term with an unfavourable cervical state, and thus facilitate delivery.     

A comparison of oral prostaglandin E2 tablets with intravenous oxytocin for stimulation of labor after premature rupture of membranes at term

Sixty-nine patients (48 primigravidae and 21 multigravidae) with 12 hours of spontaneous premature rupture of membranes (PROM) after 36 weeks gestation were randomly allocated to receive either prostaglandin E2 (PGE2) oral tablets or intravenous oxytocin to stimulate labor. The two treatments were compared regarding stimulation - delivery interval (SDI), analgesic requirements, maternal and fetal side effects, and patient acceptability. The mean SDI was shorter in the oxytocin group, but without statistical significance. Analgesic requirements and fetal side effects were similar in the two groups, but there was a higher incidence of nausea and vomiting in those patients receiving the maximum dose (1 mg hourly) of PGE2. On subjective assessment, clinicians considered oxytocin to be more effective (p less than 0.05), while midwives felt both regimes to be equally helpful. PGE2 oral tablets were significantly (p less than 0.05) more acceptable to the patients, who preferred the convenience of oral dosing, the absence of an i.v. line and the increased mobility. It is concluded that PGE2 tablets are a safe and effective method of stimulating labor following PROM, and highly acceptable to parturients. In those women in whom labor has not been established within 8 h of initiating PGE2 therapy, or in whom gastric side effects are troublesome, intravenous oxytocin should be substituted.     

Labor characteristics of uncomplicated prolonged pregnancies after induction with intracervical prostaglandin E2 gel versus intravenous oxytocin.

Labor characteristics after intracervical application of 0.5 mg prostaglandin (PG) E2 gel (n = 83) versus intravenous administration of oxytocin (n = 82) for labor induction were investigated in uncomplicated prolonged pregnancies with unripe cervix. The induction to delivery time as well as the total oxytocin dose were significantly reduced in the PGE2 group (p < 0.001). Cesarean sections, instrumental deliveries and fetal distress had the same frequency, but the failures of trial were significantly higher in the oxytocin group than in the PGE2 group (20.7 vs. 6%, p < 0.01). Twenty-four percent of women needed a second PGE2 dose, and almost half of the women in the PGE2 group experienced 'spontaneous' labor. More neonates in the oxytocin group had 5-min Apgar scores < 7 (p < 0.05). Intracervical PGE2 gel application is superior to intravenous oxytocin in terms of shortening the induction-delivery interval and increasing the frequency of successful vaginal delivery. In addition, it is safe for mother and fetus.     

Intracervical application of PGE2-gel combined with early intravenous infusion of oxytocin for induction of term labor in women with unripe cervix

Fifty-four women with an unripe cervix at term were given 0.5 mg intracervical prostaglandin E2 (PGE2) gel. In 37 of them (70%) the cervix ripened within 5 h and seven of them were in labor at that time. Of the remaining 30 patients, 15 were randomly given an i.v. oxytocin infusion and 13 were delivered within 12 h. In 17 women (30%) the cervix was still unfavorable 5 h after PGE2-gel application but seven of them had a favorable cervix when reassessed 24 h after PGE2-gel instillation. All these patients went into labor with an i.v. infusion of oxytocin. The remaining 10 patients required another dose of PGE2-gel and subsequent i.v. oxytocin. Only in two of these patients did induction fail so that delivery by Caesarean sections was required. All infants were born in good condition.     

The use of oxytocin and prostaglandin in pregnancies after cesarean delivery or uterine surgery

OBJECTIVES: Evaluation of risks involved with the use of oxytocin and prostaglandin in pregnancies after caesarean delivery or uterine surgery. MATERIALS AND METHODS: This study involved 267 pregnant women who underwent caesarean delivery or gynaecological surgery within the uterus (myomectomy or Strassmann corrective surgery). Oxytocin and prostaglandin was used to induce uterine contraction in these women. We analysed their delivery methods and the frequency of complications like uterine rupture and rupture of past caesarean scar. RESULTS: Uterine rupture occurred in one women had history of caesarean delivery (0.5%), and rupture past history of caesarean scar occurred in eight women (3.5%) who previously underwent caesarean delivery. Complications were not found in women with past history of myomectomy or Strassmann Corrective surgery. We did not observe an increase in complications among women who received prostaglandin compared to those who received oxytocin. CONCLUSIONS: 1. Cardiotocographic monitor during labour reduces the risk of uterine rupture and rupture of past caesarean scar in pregnant women with past history of caesarean delivery or other uterine surgeries. 2. The use of prostaglandin in comparison to oxytocin does not increase complications in women with past history of uterine surgery. 3. The choice of delivery method in pregnant women with past history of uterine should be individualised.     

Optimal Interval Between Prostaglandin E2 Ripening of the Cervix and Oxytocin Induction of Labor: A Prospective Clinical Trial

Does altering the interval between prostaglandin E₂ (PGE) gel application and oxytocin administration shorten induced labor without loss in efficacy? A prospective clinical trial was completed for 133 clinic patients who were candidates for the induction of labor with an unfavorable cervical status. All patients were randomly allocated to receive intracervical PGE gel 0.5 mg either 6 h or 1 h prior to the standardized administration of oxytocin. Repeat gel application and serial-day induction were offered to those judged medically stable who continued to meet inclusion criteria.

The gel to delivery duration was significantly shortened when comparing the 6-h interval to the 12-h interval only among single-day induction patients (P = 0.004) and was associated with a nonsignificant trend toward higher rates of failed induction and cesarean delivery (P = 0.073). When all patients are included, no difference between the groups was observed in the progress or outcome of labor.

A 6-h interval between PGE and oxytocin will shorten the interval to vaginal delivery only when labor is limited to a single-day attempt, but with a probable increased risk of failed induction and cesarean delivery.     

Labor induction with vaginal misoprostol and extra-amniotic prostaglandin F2alpha gel.

OBJECTIVE: To compare the effectiveness of vaginally administered misoprostol with extra-amniotic prostaglandin F2alpha (PGF2alpha) gel for induction of labor. METHOD: A randomized controlled trial, with women allocated to receive either misoprostol 50 microg intra-vaginally or extra-amniotic PGF2alpha gel 5 mg, was conducted in Harare Maternity Hospital. A total of 152 women were admitted for induction of labor with a term singleton, pregnancy and cephalic presentation were recruited. The main outcome was duration of induction. RESULTS: There were no differences in the characteristics of women in the two groups at recruitment. In the misoprostol group there was a significantly reduced need for augmentation of labor with oxytocin (OR=0.36; 95% C.I. 0.17-0.73) and delivery by cesarean section for failure to progress (OR=0.11; 95% C.I. 0.00-0.88). The risk for duration of induction to vaginal delivery exceeding 12, 18 or 24 h was reduced by 18%, 38% and 68%, respectively, but only the risk for duration >24 h was significantly reduced (OR=0.32; 95%C.I. 0.11-0.91). The mean duration of induction was shorter in the misoprostol group, 15.2 vs. 23.6 h (P=0.02). There were no differences in fetal outcome. CONCLUSION: Misoprostol 50 microg was associated with less use of oxytocin in labor, a shorter induction to delivery interval and fewer cesarean sections for failure to progress when compared with extra-amniotic PGF2alpha gel.     

Oral misoprostol versus intracervical prostaglandin E2 gel for active management of premature rupture of membranes at term

Objective

To compare the efficacy and safety of oral misoprostol with intracervical prostaglandin E2 (PGE2) gel for the active management of premature rupture of membranes (PROM) at term.

Methods

Women with pregnancies between 37 and 42 weeks presenting with PROM at term and a Bishop score of 5 or less were randomly assigned to receive either a 4-hourly oral dose of 50 µg of misoprostol up to a maximum of 3 doses or 2 applications of intracervical PGE2 gel at a 6-hour interval. Oxytocin was given if labor had not started after 12 hours.

Results

Twenty women in the misoprostol group (n = 31) delivered within 12 hours compared with 5 in the PGE2 group (n = 30) (P < 0.001). The induction-to-delivery interval in the misoprostol group was shorter than in the PGE2 gel group (615 min vs 1070 min; P < 0.001). The mode of delivery was comparable between the 2 groups (P = 0.821). Abnormalities in uterine contractions and neonatal outcomes were also comparable. The requirement for oxytocin was lower and patient satisfaction was better in the misoprostol group.

Conclusion

Oral misoprostol is a safe and efficacious alternative to intracervical PGE2 gel in the active management of PROM at term.     

Intracervical misoprostol and prostaglandin E2 for labor induction.

OBJECTIVES: To compare the safety and efficacy of misoprostol with PGE(2) for induction of labor by intracervical administration. METHODS: Eighty-six women with indications for labor induction at term were randomly assigned to two groups. Each woman received either 50 microg of misoprostol or 0.5 mg of prostaglandin E(2) intracervically. If labor was not initiated after 4 h, the same dose was repeated every 4 h to a maximum of 200 microg of misoprostol or 1.5 mg of PGE(2) until adequate labor was achieved. RESULTS: Forty-three women were allocated to the misoprostol group and 43 to the prostaglandin E(2) group. Misoprostol was more effective than PGE(2) in producing cervical changes (P<0.025). Delivery within 12 h after the first administration occurred more often in the misoprostol group than in the PGE(2) one (85% vs. 56%, P<0.05). Less patients in the misoprostol group required oxytocin augmentation than in the PGE(2) one (16.3% vs. 39.5%, P<0.05). Uterine tachysystole and hyperstimulation occurred more frequently in the misoprostol group (44.1%) than in the PGE(2) group (18.7%) (P<0.05). Nevertheless, no statistically significant differences were noted between the two groups including mode of delivery and neonatal or maternal adverse outcome. The interval from induction to vaginal delivery was significantly shorter in the misoprostol group (480+/-172 min vs. 657+/-436 min, P<0.01). CONCLUSIONS: Compared with prostaglandin E(2), intracervical misoprostol is more effective in cervical ripening and labor induction at term. The higher frequency of uterine hypercontractility associated with the use of misoprostol did not increase the risk of adverse intrapartum and neonatal outcomes.     

Early versus delayed oxytocin augmentation in nulliparous women with prolonged labour—a randomised controlled trial

Objective  To study the effects of early versus delayed oxytocin augmentation on the obstetrical and neonatal outcome in nulliparous women with spontaneous but prolonged labour.
Design  Randomised controlled study.
Setting  Two delivery units in Sweden.
Population  Healthy nulliparous women with normal pregnancies, spontaneous onset of active labour, a cervical dilatation of 4–9 cm and no progress in cervical dilatation for 2 hours and for an additional hour if amniotomy was performed due to slow progress.
Methods  Women ( n = 630) were randomly allocated either to labour augmentation by oxytocin infusion (early oxytocin group) or to postponement of oxytocin augmentation for another 3 hours (expectant group).
Main outcome measure  Mode of delivery (spontaneous vaginal or instrumental vaginal delivery or caesarean section) and time from randomisation to delivery.
Results  The caesarean section rate was 29 of 314 (9%) in the early oxytocin group and 34 of 316 (11%) in the expectant group (OR 0.8, 95% CI 0.5–1.4), and instrumental vaginal delivery 54 of 314 (17%) in the early oxytocin versus 38 of 316 (12%) in the expectant group (OR 1.5, 95% CI 0.97–2.4). Early initiation of oxytocin resulted in a mean decrease of 85 minutes in the randomisation to delivery interval.
Conclusion  Early administration of oxytocin did not change the rate of caesarean section or instrumental vaginal delivery but shortened labour duration significantly in women with a 2-hour arrest in cervical dilatation. No other clear benefits or harms were seen between early and delayed administration of oxytocin.     

A retrospective review of the efficacy and safety of prostaglandin E2 with premature rupture of the membranes at term.

OBJECTIVE: The purpose of this study was to assess rates of endometritis, clinical chorioamnionitis, cesarean delivery, and neonatal sepsis from the records of patients with premature rupture of the membranes (PROM) and an unfavorable cervix treated with vaginal prostaglandin (PG) E2 in comparison with those in the literature. METHODS: Using a computer data base at Denver General Hospital, we identified 146 women with PROM and cervical dilatation of 2 cm or less at term who were treated with PGE2 gel or suppositories. The records were reviewed to identify rates of maternal and neonatal infection and complications, as well as cesarean delivery. RESULTS: The cesarean rate was 12%. Chorioamnionitis developed in 6.8% of the study group and endometritis in 2%. Neonatal complications were limited to two with low Apgar scores (less than 7 at 5 minutes), one with microbiologically confirmed sepsis, and two with positive urine counterimmunoelectrophoresis for group B streptococcus. The only instance of neonatal sepsis occurred in a patient with rupture of membranes longer than 24 hours. CONCLUSIONS: The use of vaginal PGE2 suppositories for induction of labor and cervical ripening in term patients with PROM was accompanied by a high rate of vaginal delivery and a low rate of maternal and neonatal complications in a city hospital setting.     

Mode of delivery in pregnancies with premature rupture of membranes at or before term following induction of labor with vaginal prostaglandin E2

Our aim was to evaluate the mode of delivery in pregnancies complicated with premature rupture of the membranes (PROM) at or before term following induction of labor with vaginal application of prostaglandin E2 (PGE2), and to identify possible predictors leading to cesarean section (CS). The study sample consisted of 220 women with term-PROM who did not enter spontaneous labor after 24 hours of expectant management and 42 with preterm (P)-PROM, who underwent labor induction with vaginal PGE2. Findings were compared with 115 women admitted for elective induction of labor, and 510 women with normal spontaneous-onset labor. There were no between-group differences in gravidity, parity, nulliparity rate, or number of PGE2 tablets used. Women with P-PROM were admitted at 34.6 +/- 2.4 weeks gestation, and delivered at 36.1 +/- 1.6 weeks (mean interval, 5.0 +/- 7.9 days; range, 0.5 to 40 days). The rate of CS was different only between the term-PROM (18.6%) and spontaneous onset of labor (9%) groups (odds ratio, 2.08; 95% confidence interval, 1.4 to 3.4). The rate of low 5-minute Apgar score (< 7) was similar in all groups, but the incidence of nonreassuring fetal heart rate pattern leading to CS was significantly lower in the PROM groups. A logistic regression model and forward likelihood analysis in the PROM groups yielded parity, higher number of PGE2 tablets used, and higher birth weight as independent and significant variables associated with increased risk of CS. Using our management protocol, 36.4% and 20.4% of women with term-PROM and P-PROM, respectively, required labor induction with PGE2, which was successful in more than 80% of cases, with no apparent serious maternal or fetal complications.     

Vaginal prostaglandin E2 gel versus tablet in the induction of labour at term--a retrospective analysis.

Our aim in this retrospective analysis was to compare labour outcomes between 145 consecutive women with unfavourable cervices, who received prostaglandin E2 vaginal gel (1-2 mg) for labour induction over a 3-month period, and 149 women receiving a prostaglandin E2 vaginal tablet (3 mg) over the following 3 months. Our results showed that cervical dilatation in the gel group was significantly more than in the tablet group at transfer to labour ward [4 cm (SD 2.5 cm) versus 3.3 cm (SD 2 cm), mean difference -0.7, 95% CI -1.2 to -0.2, P=0.01), with fewer women requiring oxytocin augmentation, but this was not statistically significant (41.4% versus 50%, RR 0.8, 95% CI 0.7-1.1). There were no significant differences in the mode of delivery in the number delivering vaginally within 24 hours of the induction (60.4% in the gel group versus 56.2% in the tablet group, RR1.1, 95% CI 0.9-1.4), in the number of doses of PGE2 administered, or in the neonatal outcomes between the two groups. In conclusion, there were no significant differences in labour or neonatal outcomes between prostaglandin E2 gel or tablet use in the induction of labour in this retrospective analysis.     

Labour Induction with Low Dose PGE2 Vaginal Gel: Result of an Australian Multicentre Randomized Trial*

An open-label, parallel, randomized study was conducted in 6 Australian hospitals involving 320 women near term who required induction of labour. Labour induction with 1 or 2mg of PGE2 in a vaginal triacetin gel repeated if necessary at 6 hours was compared to induction by amniotomy and intravenous oxytocin. Analysis of the 2 groups confirmed matching with regards demographic and clinical data. A significantly longer and more variable mean induction to onset of established labour interval was recorded in the PGE2 group (6.7 +/- 4.8 versus 2.0 +/- 1.1 hours. (p less than 0.001). The mean period of established labour was also longer (8.1 versus 6.0 hours, p less than 0.001) in the PGE2 group. However, 48% of PGE2 treated patients versus 29% oxytocin treated patients (p less than 0.01) were recorded as not experiencing strong contractions. Twelve hours after induction 65% of the PGE2 group and 93% of the oxytocin group were in established labour; 24% of the PGE2 treated group required subsequent augmentation with oxytocin. Spontaneous delivery occurred in 69% of PGE2 treated women and 62% of those treated with oxytocin (N.S.). Analgesic requirements were not statistically different between the groups. Fewer fetal heart rate abnormalities were recorded in the PGE2 treated group (p less than 0.02). No serious and only minimal adverse events were recorded in either treatment group.