Pre-induction cervical ripening with prostaglandin E2 gel: intracervical versus intravaginal route

The aim of our study was to evaluate the best method for cervical ripening before a classical induction with amniotomy and oxytocin. One hundred term pregnant patients who presented an unfavorable cervix and an indication for the induction of labor were assigned randomly to either 0.5 mg prostaglandin (PG) E2 gel intracervically (N = 52) or 3 mg PGE2 gel intravaginally (N = 48). The intravaginal gel had a greater effect on cervical ripening according to a modification of the Bishop score than did intracervical gel, but it had a higher incidence of side effects.     

四种引产方法随机比较及其血前列腺素E水平的观察分析

目的 前瞻性对照组研究４种引产方法的时效及对母儿的影响,了解血前列腺素Ｅ水平变化与引产方式的关系。方法 将１２４足月单胎头位具有引产指征、宫颈评分≤４分的孕妇随机分组,其中催产素组２８例,水囊组２８例,米索前列醇组２５例,前列腺素Ｅ２凝胶组４３例。各种方法使用后如宫颈评分≥７分则行人工破膜。各组产妇在用药前、用药后６小时、宫口开全分别取血,用放免法查血ＰＧＥ水平。统计学分析引产时效、母儿并发症及血     

Cervical ripening before medical induction of labor: a comparison of prostaglandin E, estradiol, and oxytocin

Objective: Our purpose was to evaluate the effectiveness of oxytocin, prostaglandin, E² intracervical gel, and estradiol cream for ripening the very unfavorable cervix in patients requiring induction of labor at term.Study design: This prospective, randomized study was conducted in a population of women with a very unfavorable cervix (Bishop score <4) requiring induction of labor. The patients received prostaglandin E² gel (0.5 mg) intravervically (three doses 6 hours apart), 4 mg estradiol cream in the anterior fornix of the vagina (three doses 6 hours apart), or oxytocin at induction per protocol with an infusion pump.Results: Ninety-nine women were recruited into this trial and evenly distributed among the three groups. The demongraphics of maternal age, race, parity, gestational age, initial Bishop score, and indication for induction were similar among the groups. The incidence of cesarean deliveries was similar in the three groups with approximately 59% of pregnancies delivered abdominally. For patients undergoing abdominal delivery the maximum cervical dilatation among the oxytocin, estradiol, and prostaglandin E² groups was similar (3.90 = 3.02 cm, 3.63 ± 2.79 cm, and 4.65 ± 2.78 cm, respectively; p > 0.05). For all patients birth weight and Apgar scores at 1 and 5 minutes were comparable across all regimens (p > 0.05). In the subset of patients delivered vaginally patients receiving oxytocin for cervical ripening had the greatest improvement on Bishop score over baseline (p = 0.023) with an improvement of 7.08 ± 2.42.Conclusion: No differences were detected among prostaglandin E₂ gel, estrogen, and oxytocin in relation to cervical ripening in patients with an unfavorable cervix at term who require an induction of labor. Patients with a very unfavorable cervix at term who require delivery may benefit from serial ripening and inductions.     

Digital and transvaginal ultrasound cervical assessment for prediction of successful labor induction.

OBJECTIVE: To compare the values of preinduction transvaginal cervical length measurements and Bishop score to predict successful labor induction. METHODS: A prospective, observational trial of nulliparous women undergoing labor induction. Inclusion criteria were gestational age between 36 and 42 weeks, singleton cephalic presentation of the fetus, and intact membranes. Preinduction cervical ripening was performed using 25 microg intravaginal misoprostol (PGE1), repeated every 4 h, up to a maximum of 3 doses. Induction was subsequently continued by oxytocin and amniotomy. RESULTS: A total of 43 women met the inclusion criteria. Mean preinduction cervical length for women with successful or failed labor induction was 26 mm (95% Confidence interval [CI], 27-32) and 34 mm (95% CI, 33-38), respectively (P=0.002). Mean Bishop scores for successful and failed induction groups were 5.4 (95% CI, 5.2-6.2) and 3.1 (95% CI, 2.8-3.5), respectively (P=0.003). CONCLUSION: Digital examination and transvaginal ultrasound of the cervix predict successful labor induction with reasonable accuracy.     

Cervical ripening with prostaglandin E1: how an ambulatory method decreases the hospital stay in abortus with intrauterine fetal demise

OBJECTIVE: This study was designed to determine whether use of prostaglandin E(1 )(PGE(1)) is justified to improve the known clinical outcome of prostaglandin E(2) (PGE(2)) gel, because PGE(2) gel preparations are more costly than PGE(1) tablets in most countries, and data to support the use of the gel in clinical practice is not conclusive. The aim was to compare the safety and efficacy of PGE(1) gel when applied in both an in-hospital or ambulatory setting to oxytocin infusion in those women with unfavorable cervical conditions prior to surgical abortion for either medical or obstetrical indications with intrauterine fetal demise. Surgical dilatation of the unripe cervix may result in cervical injury of uterine perforation which could prolong the hospital stay. METHODS: We used PGE(1) gel prepared from tablets and administered in the ambulatory form (group 1), the same PGE(1) gel administered in the labor room (group 2) and intravenously administered oxytocin in the labor room (group 3) for the induction of abortus in women complicated with intrauterine fetus death and missed abortion. Patients requesting abortion were eligible for inclusion, with >8 and <13 weeks of gestation. Eighty-nine women with unfavorable cervices (Bishop score 相似文献   

Lamicel for induction of labor

Lamicel is a synthetic osmotic cervical dilator currently used as a method of cervical dilation in first- and second-trimester pregnancy termination. It works by extracting fluid from the cervical tissue and softening the cervix. This study evaluated its effectiveness in nonelective medical induction of labor in high-risk patients. Forty inpatients who, for medical and obstetric reasons, required delivery within the next 24-48 hours were studied. Patients were evaluated to make certain that a 12- to 24-hour delay was safe for mother and child. The evening prior to the day of induction, a pelvic examination determined the Bishop score, and bacterial cultures were obtained from the endocervix. As many Lamicels as possible (usually one to three) were then placed in the endocervix without rupturing the membranes. The next morning the devices were removed, a repeat Bishop score obtained, amniotomy performed, internal monitors placed and oxytocin infusion initiated. Data were collected for preinsertion and postinsertion Bishop scores, induction-delivery times, duration of ruptured membranes, and cesarean and vaginal birth rates. Maternal and neonatal infectious morbidity was determined. A comparison group of patients with premature rupture of the membranes was selected. From data studied at our institution, patients were matched for parity and duration of labor (not significantly different from the Lamicel group). The study revealed that Lamicel can be an effective means of ripening the cervix for induction of labor.     

Laminaria as an adjunct in induction of labor

The safety and efficacy of laminaria tents as an adjunct to labor induction near term were examined in a prospective, controlled, and randomized study involving insertion of laminaria into the cervical canal the evening prior to planned induction. Six of 35 subjects in whom laminaria were used entered labor spontaneously and delivered overnight, compared with 1 of 39 controls. Of the remainder, the Bishop score increased an average of 3.7 points, a highly significant change, in the laminaria-treated group compared with no change in the controls. Labor, induced primarily by amniotomy with intravenous oxytocin then given to patients in whom regular contractions did not begin within 8 hours, was shorter with laminaria use than in controls, though the amniotomy-to-delivery interval did not differ significantly. However, comparison of the subgroup with cervices relatively unfavorable for induction, indicated by an initial Bishop score of 5 or less, showed both length of labor and amniotomy-to-delivery interval to be significantly shorter (each by an average of 3 hours) in the laminaria-treated group compared with controls. Complications, including febrile morbidity, did not differ. We conclude that laminaria tents are both effective and safe as an adjunct to labor induction, acting by accelerating the preparatory changes in the cervix which normally occur in late pregnancy.     

Obstetric outcomes after cervical ripening by multiple doses of vaginal prostaglandin E2

AIM: The study was designed to investigate the delivery outcome in women who required vaginal prostaglandin E2 for cervical priming prior to labor induction. MATERIALS AND METHODS: This retrospective cohort study included all singleton term deliveries that required labor induction over a 3-year period. Incidence and indications of obstetric interventions were compared among women who required different doses of vaginal prostaglandin E2 for cervical priming and who had induction by amniotomy and oxytocin infusion. RESULTS: Of 706 deliveries, 411 had favorable Bishop's scores and no vaginal prostaglandin E2 for cervical priming was required (group A); 268 required one or two doses of vaginal prostaglandin E2 for cervical priming (group B); and 27 required three or more doses (group C). The incidence of cesarean section was significantly higher in group C (48.1%) than in group A (19.0%) and group B (16.4%). The difference remained statistically significant when primiparous and multiparous women were analyzed separately. The risk of obstetric intervention was particularly high in primiparous women in group C (58.8% required emergency cesarean section and 23.5% had instrumental delivery). There was an increased frequency of all major indications for cesarean section in group C. CONCLUSION: The risk of emergency cesarean section was higher in women who required more than two doses of vaginal prostaglandin E2 for cervical priming compared to induction by one or two doses of vaginal prostaglandin E2 or by amniotomy and oxytocin infusion. These women should be informed regarding the high risk of intrapartum cesarean section, and the option of alternative methods of induction or elective cesarean section should be made available.     

Induction of Labour in Nulliparas with Poor Cervical Score: Oxytocin or Prostaglandin Vaginal Pessaries?

In a previous study nulliparas with poor cervical score (less than 5 out of 10) had a 43.5% Caesarean section (CS) rate of which 55% were for failed induction when labour was induced by artificial rupture of membranes and oxytocin infusion. In this study induction of labour by 2 doses of 3 mg prostaglandin E2 (PGE2) vaginal pessaries, 4 hours apart, and if necessary by artificial rupture of membranes and oxytocin infusion 24 hours later, resulted in a CS rate of 23.7% of which 38.9% were for failed induction. The latter regimen resulted in a significantly lower CS rate compared with labour induced by oxytocin infusion and rupture of membranes without the use of prostaglandins (p less than 0.001). In the prostaglandin group 53.3% were established in labour within 24 hours of inserting the pessary and in these patients the CS rate was 18.5%. In those who did not start labour and needed rupture of membranes and oxytocin infusion 24 hours after the first pessary, 34 (47.9%) had a good cervical score (greater than or equal to 6 out of 10) and 37 (52.1%) had a poor cervical score (less than or equal to 5 out of 10) at the time of amniotomy. The CS rates in these groups were 8.8% and 48.6% respectively (p less than 0.001). In nulliparas with poor cervical score induction is better performed with vaginal prostaglandin pessaries in order to reduce the high CS rate associated with artificial rupture of membranes and oxytocin infusion.     

Sonographic cervical length measurement before labor induction in term nulliparous women

OBJECTIVE: The purpose of the study was to determine if transvaginal sonographic measurement of the cervical length is a useful method to predict successful labor induction in nulliparas. METHODS: 137 women who were scheduled for medically indicated induction of labor had a transvaginal sonographic measurement of the cervical length before labor induction. Inclusion criteria were: (1) singleton pregnancy; (2) gestational age between 37-42 weeks; (3) live fetus in cephalic presentation; (4) intact membranes; (5) no vaginal bleeding; (6) no previous history of uterine surgery; (7) nulliparous women, and (8) no allergy or asthma in response to prostaglandins. Induction of labor was performed within 6 h of the ultrasonographic examination, by inserting 2 mg of dinoprostone in the posterior vaginal fornix, repeated if needed every 6 h for up to three doses. When the cervix became favorable and no regular contractions were observed, amniotomy and oxytocin augmentation, starting at 1 mIU/min and increasing 1 mIU every 30 min as necessary, was performed. RESULTS: All women were Caucasians and the mean age was 24.3 years (range 19-37 years). The mean cervical length was 28 mm (range 11-39 mm). The Bishop score was < or =5 in 101 women and >5 in the 36 others. Vaginal delivery occurred in 92 women (67.1%), and the vast majority of them (89 women; 96.7%) gave birth within 24 h of induction. Forty-five women (32.8%) had a cesarean section. The Bishop score was not predictive of the mode of delivery. Thirty-six of 101 women (35.6%) with a Bishop score < or =5 delivered by cesarean section, compared to 9 of 36 women with a Bishop score >5 (25%) (p = NS). Women with a cervical length <27 mm were more likely to deliver vaginally. Using this cutoff value the sensitivity of a successful labor induction was 76% and the specificity was 75.5%. CONCLUSIONS: Transvaginal sonographic measurement of cervical length is a good predictor of a successful labor induction at term in nulliparas.     

Randomized comparison of glyceryl trinitrate and prostaglandin E2 for cervical ripening at term

OBJECTIVE: To estimate the adverse effects of glyceryl trinitrate compared with prostaglandin (PG) E2 vaginal tablet for cervical ripening in term pregnancy. METHODS: One hundred ten women with term pregnancies referred for induction of labor with Bishop scores of 6 or less were randomly assigned to receive a 500-microg glyceryl trinitrate tablet vaginally (n = 54) or a 3-mg PGE2 tablet vaginally (n = 56), every 6 hours for maximum of two doses. Subjects were sent to the labor ward for amniotomy or oxytocin if their Bishop scores were more than 6 or their cervices were not ripe 24 hours after treatment. Adverse effects, changes in the Bishop scores, progress, and outcomes of labor were assessed. RESULTS: Glyceryl trinitrate was associated with fewer episodes of uterine tachysystole (0% versus 9%; P =.02). The median Bishop score after 12 hours was lower in women given glyceryl trinitrate compared with those given PGE2. Adverse effects, including headache and palpitations, were more frequent with glyceryl trinitrate than with PGE2. The cesarean rate was not significantly different between groups. CONCLUSION: Cervical ripening with glyceryl trinitrate resulted in fewer episodes of tachysystole, but there were significantly more minor side effects. It can be used for cervical ripening at term, but it was not as effective as PGE2.     

Induction of labor and cervical ripening with oral PGE2 in risk pregnancies. A placebo-controlled study

A double-blind, placebo-controlled study was undertaken to evaluate the priming effect on the cervix and also the effect on the subsequent induction of labor. 0.5 mg oral PGE2 or placebo was given hourly for two 12-h periods. A total of 191 women with risk pregnancies and Bishop score less than or equal to 5 were studied. The induction of labor was carried out with oxytocin or oral PGE2 in a randomized manner. Labor was induced in 39% of the women during the PGE2 priming. The best result, 71% vaginal deliveries, was achieved with the combination of PGE2 priming and induction of labor with oxytocin.     

Cervical ripening and labor induction with prostaglandin E2 gel: a placebo-controlled study

A randomized double-blind, placebo-controlled study was undertaken to evaluate the effect of a single intracervical application of prostaglandin E2 gel on the ripening of the cervix and on the subsequent induction of labor with oxytocin in patients with low Bishop scores (less than or equal to 4). Compared to controls receiving gel only, the group receiving prostaglandin E2 gel had significant increases in their cervical Bishop scores, shorter induction-to-delivery intervals, shorter time requiring use of oxytocin, and more successful labor induction without oxytocin. Systemic side effects were minimal and fetal outcomes were comparable, as were the routes of delivery.     

Induction of labor in the postdate fetus

Once a decision to induce a postdate pregnancy is reached, the likelihood of achieving a vaginal delivery can be predicted by the Bishop or pelvic score and the willingness or lack thereof to commit to sequential inductions. Cesarean delivery rates will be significantly increased if an amniotomy is performed in the woman with an unfavorable cervix. Accordingly, we advocate sequential induction of the postdate pregnancy in the absence of other maternal or fetal mandates for imminent delivery. A host of oxytocin induction protocols exist and are acceptable, as are guidelines for what constitutes an adequate labor pattern. Although an increasing number of agents are available for cervical ripening, for the foreseeable future dilute intravenous oxytocin will remain the labor induction agent of choice.     

Using of Misoprostol for preinduction and induction of labor in term pregnancy

Labour induction is frequently indicated in women with an unfavourable cervix. Oxytocin and prostaglandins are the most common drugs used for labour induction. Induction of labour with prostaglandins offers the advantage of promoting both cervical ripening and myometrial contractility. The purpose of the study was to evaluate the safety and efficacy intravaginal administration prostaglandin E1 methyl analogue, misoprostol in cervical ripening and induction of labour in term pregnancy and in women with unfavourable cervix (Bishop score < = 4). The approval for this study was given by the Board of Medical Ethics, University Medical School of Lublin in Poland. MATERIALS AND METHODS: 64 women with indication for termination of pregnancy received either misoprostol (Cytotec-Searle) vaginally (group M, n = 30) or intravenous drip infusion of oxytocin(group Ox, n = 34). We evaluated profile of the studied women (gravidity, weight, height, maternal age, gestational age), effectiveness and safety of the misoprostol and need for oxytocin administration in group M, start of induction-to-active labour interval (contractions), start of induction-to-vaginal delivery interval, hyperstimulation syndrome, delivery within 24 hours of drug application and caesarean section rate. Before starting labour induction a Bishop score was obtained. Statistical analysis was performed. Baseline and outcome variables were tested with student's t-test and c2 analysis. We needed p < 0.05 for statistical significance. RESULTS: There were no differences in the patient profiles (gravidity, weight, height, maternal age, gestational age) between groups except the score of cervical ripening. The Bishop score before induction was lower in group M. The interval between the initiation of induction to active labour was shorter in the misoprostol group (334.23 +/- 126.35 versus 610.00 +/- 352.14 minutes). The mean time between the initiation of induction to delivery was shorter in group M (707.69 +/- 341.15 +/- versus 1025.77 +/- 369.16 minutes). These differences were statistically significant. 28 (93.33%) patients in the misoprostol group delivered within 24 hours compared with 24 (70.59%) women in the oxytocin group. 8 patients in the misoprostol group and 8 patient in the oxytocin group had caesarean section. Labor induction was successful in 30 (100%) women in the misoprostol group compared with 24 (70.59%) patients in the group Ox. CONCLUSIONS: Intravaginal misoprostol is an effective, easy to use and cheap drug for the induction of labour, especially for cervical ripening in women with unfavourable cervix (Bishop score < = 4).     

Comparison of prostaglandin E2 and intravenous oxytocin for induction of labor

One hundred nulliparas at term were randomly given oxytocin intravenously or prostaglandin E2 (PGE2) gel (0.5 mg PGE2) intracervically in order to study the effect on cervical ripening and the frequency of successful inductions. In the presence of a favorable cervix both methods seemed equally efficacious in inducing labor. However, when the cervix was unfavorable, 53% of the patients could be delivered with PGE2 gel, compared with 31% when oxytocin was given. In patients with a highly unfavorable cervix this difference was significant (P less than 0.02). In patients not induced into labor, PGE2 gel caused a considerable ripening of the cervix, with a change in Bishop score from 2.9 to 6.3. In patients undelivered after oxytocin stimulation, no change in Bishop score occurred. This effect of locally applied PGE2 gel on cervical ripening was highly significant (P less than 0.001). No adverse maternal or perinatal effects were observed, irrespective of the mode of treatment.     

Transcervical Foley catheter with and without extraamniotic saline infusion for labor induction: a randomized controlled trial

OBJECTIVE: To compare the efficacy of transcervical Foley catheter alone (Foley) to transcervical Foley catheter with extraamniotic saline infusion for labor induction and cervical ripening in women with an unfavorable cervix. METHODS: This was a multicenter, randomized, controlled trial of women presenting for labor induction with a singleton, cephalic fetus, intact membranes, and unfavorable cervix (Bishop score 6 or less). Eligible women were randomly assigned to receive either Foley catheter alone or Foley catheter with extraamniotic saline infusion. All women received concurrent oxytocin administration. The primary study outcome was the induction-to-delivery interval. Secondary outcomes included cesarean delivery, maternal infectious outcomes, and immediate neonatal outcomes. Analysis was by intent to treat. RESULTS: One hundred eighty-eight women met eligibility criteria and were randomly assigned (Foley plus extraamniotic saline infusion, n=97; Foley, n=91). Baseline demographic characteristics, including parity, gestational age, and Bishop score were similar between the study groups. The median induction-to-delivery interval in the extraamniotic saline infusion arm (12.6 hours, interquartile range 9.3-18.8 hours) was similar to that in the Foley arm (13.4 hours, interquartile range 9.6-17.5 hours) (P=. 70). The proportion of women delivered by 24 hours was comparable between groups (delivery 24 hours, extraamniotic saline infusion 89.7%, Foley 87.9%, P=.70), as was the rate of cesarean delivery (Foley 18.7%, extraamniotic saline infusion 27.8%, P=.14). No significant differences were noted between the study groups with respect to rate of chorioamnionitis, endometritis, or immediate birth outcomes. CONCLUSION: In women with an unfavorable cervix, the addition of extraamniotic saline infusion to a transcervical Foley catheter does not improve efficacy for labor induction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00442663 LEVEL OF EVIDENCE: I.     

Characteristics of oral prostaglandin E2-induced labor

Oral prostaglandin E2 appears to play a dual role in human parturition. It induces normal uterine contractions and softens the cervix, thereby decreasing the resistance of the cervix to dilatation. Labor and delivery with oral PGE2 is achieved with less total uterine work when compared with spontaneous nonstimulated labor. This contention is supported by the fact that the rate of cervical dilatation in the active phase of labor is faster (2.73 cm/hr) than that reported by Hendricks et al. for ideal labor (2.12 cm/hour), yet uterine contractility is not increased. Analysis of the composite data of Friedman and Sachtleman in 1974 also shows a more rapid active phase dilatation in the PGE2-stimulated labors (3.3 cm/hour) as compared with spontaneous labor (2.98 cm/hour). Oral PGE2 offers a safe and efficacious alternative to oxytocin for the induction of labor in women. It appears to have a major advantage over oxytocin. The softening effect of PGE2 on the cervix would make this drug an ideal agent for use in patients with low Bishop scores who have medical indications for induction of labor. Regardless of route of administration, prostaglandin E2 is a potent uterine stimulant and must be used with the same precautions and safeguards as intravenous oxytocin.     

Preparation for Induction of Labour of the Unfavourable Cervix with Foley Catheter Compared with Vaginal Prostaglandin

Ripening of the unfavourable cervix prior to induction of labour using traction on a Foley catheter (32 patients) was compared with 40 mg of prostaglandin F2 alpha in Tylose gel applied to the external cervical os and held in place for 12 hours with a vaginal diaphragm (25 patients). Each patient in the above groups had a modified Bishop score of 0-3 and was randomly allocated to one or other group. Comparison was made with a further 25 patients in whom the cervical score was 4-6. Timing of amniotomy and commencement of Syntocinon infusion were equivalent for all patients. Prostaglandins conferred no advantage over Foley catheter in terms of amniotomy-delivery interval, operative delivery rate, and condition of the baby one minute after birth. The disadvantages of prostaglandins for cervical ripening are a longer preparation-delivery interval, and cost ($77 versus $4.75 for the Foley catheter). Currently, prostaglandins are not officially approved for use in Australia for induction of labour. It is suggested, therefore, that the Foley catheter is preferable for ripening the unfavourable cervix as a prelude to amniotomy.     

Evaluation of the effect of extra-amniotic normal saline infusion alone or in combination with dexamethasone for the induction of labor

AIM: To compare the effect of extra-amniotic normal saline solution infusion on its own, and in combination with dexamethasone on the ripening of the cervix and induction of labor. METHODS: A double-blind randomized clinical trial study was performed at Akbar Abadi Teaching Hospital in Tehran, Iran, between March 2002 and March 2003 on 84 pregnant women at a gestational age of 40 weeks or more, and with a Bishop score 相似文献