Membrane sweeping in conjunction with labor induction

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

Six hourly vaginal misoprostol versus intracervical dinoprostone for cervical ripening and labor induction

AIM: Prospective clinical trials were conducted to assess the safety and efficacy of 6-hourly vaginal misoprostol versus intracervical dinoprostone for induction of labor. METHODS: A total of 120 pregnant women requiring induction of labor were recruited. Cases were randomized to receive either 50 microg vaginal misoprostol 6 hourly (group 1, n = 60) or 0.5 mg intracervical dinoprostone 6 hourly (group II, n = 60). Outcome measures, such as change in Bishop's score, need of oxytocin, induction delivery interval; complications like tachysystoly, hyperstimulation, abnormal fetal heart rate, and meconium passage were compared between two groups. Statistical analysis was performed by Wilcoxan's Rank sum and Student's t-test. RESULTS: Bishop score rise, after 6 h of initiation of therapy was significantly higher in the misoprostol group than dinoprostone, 2.98 +/- 2.57 versus 2.05 +/- 1.83 (P = 0.04). The need of oxytocin augmentation was reduced in misoprostol versus dinoprostone group, 16.6% versus 78.3% (P = <0.001). Induction delivery interval was shorter in misoprostol; 12.8 +/- 6.4 h versus 18.53 +/- 8.5 h in dinoprostone group (P = <0.01). One case (1.6%) in misoprostol group, but none in dinoprostone had tachystole (P = 1.00). Abnormal heart rate pattern was found more in misoprostol than dinoprostone 16.6% versus 4.9% (P = 0.14) and so was the incidence of cesarean section, 26.6 versus 15%, respectively (P = 0.47). Meconium passage was the same in both groups, 10% in each group. CONCLUSION: Vaginal misoprostol 50 microg 6-hourly is safe and effective for induction of labor with lesser need of oxytocin augmentation and shorter induction delivery interval.     

Comparative efficacy and cost of the prostaglandin analogs dinoprostone and misoprostol as labor preinduction agents

OBJECTIVE: The purpose of this study was to compare the relative efficacy and cost of three commercially available prostaglandin analogs, misoprostol (Cytotec), dinoprostone gel (Prepidil), and dinoprostone insert (Cervidil), as labor preinduction agents. STUDY DESIGN: One-hundred eleven women with an unfavorable cervix who underwent labor induction were assigned randomly to receive either misoprostol 50 microg every 6 hours for two doses, dinoprostone gel 0.5 mg every 6 hours for two doses, or dinoprostone insert 10 mg for one dose intravaginally. Twelve hours later, oxytocin induction was initiated per standardized protocol. Efficacy and cost of the labor preinduction/induction with the study treatments were compared. RESULTS: Mean Bishop score change (+/-SD) over the initial 12-hour interval was significantly greater in the misoprostol group (5.2 +/- 3.1) compared with the dinoprostone insert (3.2 +/- 2.3) or the dinoprostone gel groups (2.2 +/- 1.3, P <.0001). The proportion of women who reached complete dilation (68.4%, 50.0%, 51.4%, respectively; P =.14) and who were delivered (60.5%, 47.4%, 40.0%, respectively; P =.10) within 24 hours of the initiation of induction were not significantly different between the misoprostol, dinoprostone insert, and dinoprostone gel groups. Induction-to-delivery intervals, however, were significantly shorter among women who treated with misoprostol (24.0 +/- 10.8 hours) compared with either the dinoprostone gel (31.6 +/- 13.4 hours) or the dinoprostone insert (32.2 +/- 14.7 hours, P <.05). Overall mean cost per patient that was incurred by labor induction was significantly less for the misoprostol group ($1036.13) compared with the dinoprostone insert group ($1565.72) or the dinoprostone gel group ($1572.92, P <.0001). No significant differences were noted with respect to the mode of delivery or to the adverse maternal/neonatal outcome. CONCLUSION: Misoprostol is more cost-effective than the comparable commercial dinoprostone prostaglandin preparations as an adjuvant to labor induction in women with an unfavorable cervix.     

Randomized trial between two active labor management protocols in the presence of an unfavorable cervix

OBJECTIVE: The purpose of this study was to compare the efficacy of two protocols for active management of labor at term in the presence of an unfavorable cervix. STUDY DESIGN: Pregnancies that underwent labor induction at > or =37 weeks of gestation with an unfavorable cervix (Bishop score, < or =6) were randomly assigned to receive vaginally either a single dose of sustained-release dinoprostone (Cervidil) with concurrent low-dose oxytocin or multidosing of misoprostol (25 microg every 4 hours) followed by high-dose oxytocin. The primary outcome was the time interval from induction to vaginal delivery. Other parameters included excess uterine activity and cesarean delivery rates. RESULTS: A total of 151 patients (dinoprostone, 74 patients; misoprostol, 77 patients) were enrolled. The mean time from the initiation of induction to vaginal delivery was the same in the dinoprostone and misoprostol groups (15.7 hours; 95% CI, 13.7-17.7 hours vs 16.0 hours; 95% CI, 14.1-17.8 hours; P=.34), regardless of parity. The dinoprostone and misoprostol groups did not differ statistically in the percent of patients who were delivered vaginally by 12 hours (36.2% vs 29.7%), 18 hours (63.8% vs 56.3%), and 24 hours (81.0% vs 81.3%). Excess uterine activity was not more common in either group, and hyperstimulation syndrome was absent in all cases. Primary cesarean delivery rates were similar (dinoprostone, 21.6%; misoprostol, 16.9%; relative risk, 1.3; 95% CI, 0.7-2.5), with a failed induction that occurred in one case in each group. CONCLUSION: Sustained-release dinoprostone with concurrent low-dose oxytocin and intermittent misoprostol with delayed high-dose oxytocin are effective alternatives for active management of labor with an unfavorable cervix.     

Outpatient misoprostol compared with dinoprostone gel for preinduction cervical ripening: a randomized controlled trial

OBJECTIVE: To determine whether a single outpatient dose of intravaginal misoprostol (versus intracervical dinoprostone gel) reduces the oxytocin use for induction. Despite the numerous trials examining misoprostol for induction, the efficacy of a single outpatient dose of misoprostol followed by oxytocin induction is unknown. METHODS: Patients with a term, vertex, singleton pregnancy and a Bishop score of 6 or less were randomly assigned to receive misoprostol (n = 42, 0.25 microg intravaginally) or dinoprostone gel (n = 42, 0.5 mg intracervically) the evening before oxytocin induction. Patients were monitored for 3 hours after administration and discharged to home if fetal assessment was reassuring, for readmission the next morning for oxytocin. Primary outcomes were oxytocin dose, time, and dose intensity (dose divided by duration). Secondary outcomes were incidence of labor, uterine hyperstimulation, cesarean delivery, Apgar score. Statistics used were chi(2), Student t test, Mann-Whitney rank sum test, and Fisher exact test. P < .05 was accepted as statistically significant. RESULTS: A single dose of misoprostol significantly decreased the cumulative dose of oxytocin, the cumulative time of oxytocin administration, and the dose intensity of oxytocin (dose divided by time). Data are as follows (mean +/- standard error of the mean): oxytocin dose-dinoprostone 10,929 +/- 219 mU, misoprostol 6,081 +/- 170 mU, P = .008; oxytocin time-dinoprostone 798 +/- 11 minutes, misoprostol 531 +/- 11 minutes, P = .009; dose intensity-dinoprostone 11.3 +/- 0.1 mU/min, misoprostol 7.4 +/- 0.2 mU/min, P = .003. Misoprostol induced labor during the ripening period in 19 of 41 of patients, compared with 6 of 42 after dinoprostone (P = .002). There was no difference in cesarean delivery (dinoprostone, 8/42; misoprostol, 9/42; P = 1.00). There was no difference in short-term neonatal outcome. No patient had hyperstimulation or required cesarean delivery for nonreassuring fetal assessment during the ripening period. CONCLUSION: A single dose of misoprostol administered in the outpatient setting significantly decreases oxytocin use, largely due to labor within the ripening period.     

Concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labour induction of nulliparas with an unfavourable cervix: a randomised placebo-controlled trial

Objective  To compare concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labour induction for nulliparas with an unfavourable cervix.
Design  A randomised double-blind study.
Setting  University Malaya Medical Centre, Malaysia.
Population  Nulliparas at term with intact membranes, Bishop score ≤ 6 and admitted for labour induction.
Methods  All women received 3 mg dinoprostone pessary for labour induction. Those randomised to the oxytocin arm received oxytocin infusion started at 1 mu/minute and doubled every 30 minutes to a maximum 16 mu/minute. Women assigned to placebo received identical volume of saline infusion. After 6 hours, infusion was stopped and vaginal reassessment performed to guide further management.
Main outcome measures  Primary outcome was vaginal delivery within 24 hours.
Results  Concurrent oxytocin infusion with dinoprostone pessary did not significantly increase vaginal delivery rate within 24 hours (48.6 versus 35.9%; P = 0.07, relative risk [RR] 1.4 [95% CI 1.0–1.9]). It reduced the requirement for repeat dinoprostone (37.1 versus 61.2%; P = 0.001, RR 0.61 [95% CI 0.45–0.81]) and improved maternal satisfaction with the birth process (median score of 3 versus 5 on a 10-point visual analogue scale, P = 0.007). Caesarean rates were not different (41.9 versus 44.7%, P = 0.52).
Conclusions  Labour induction with concurrent oxytocin infusion and vaginal dinoprostone could be considered for nulliparas with an unfavourable cervix. Larger studies are needed.     

Effect of vaginal pH on efficacy of the dinoprostone gel for cervical ripening/labor induction

OBJECTIVE: The purpose of this study was to evaluate whether vaginal pH has an effect on the efficacy of the dinoprostone gel for cervical ripening/labor induction. STUDY DESIGN: Thirty-two women with an unfavorable cervix who were undergoing labor induction were enrolled in this prospective, double-blinded investigation. Initial vaginal pH and Bishop score assessment were made by an independent examiner. All women received cervical ripening with the dinoprostone gel 5 mg intracervically, with repeated dosing one time 6 hours later. Twelve hours later, oxytocin induction was initiated per standardized protocol, and outcome data were collected. RESULTS: Mean (+/-SD) initial vaginal pH was 4.7 +/- 0.6 (range, 4.0-6.0) for the study cohort. No significant differences were noted between women with a high vaginal pH (>4.5, n = 16 women) and women with a low vaginal pH (< or =4.5, n = 16 women) with respect to maternal age, parity, gestational age, or initial Bishop score. Although Bishop score change over the initial 12 hours of cervical ripening did not significantly differ between the high vaginal pH (2.3 +/- 2.3) and the low vaginal pH group (2.3 +/- 2.5, P = not significant), time to active labor (19 +/- 10 hours vs 33 +/- 17 hours, P =.001), complete dilation (24 +/- 10 hours vs 37 +/- 19 hours, P =.03), and delivery (26 +/- 10 hours vs 38 +/- 18 hours, P =.02) were significantly shorter in women with a high vaginal pH compared with women with a low vaginal pH, respectively. A significant association was noted between vaginal pH and time to active labor (r = -0.52, P =.003), complete dilation (r = -0.50, P =.006), and delivery (r = -0.44, P =.01); however, pH was not significantly associated with Bishop score change during the initial 12 hours of cervical ripening. CONCLUSION: Vaginal pH is an important factor that affects the efficacy of the dinoprostone gel as an adjuvant for labor induction.     

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).     

Induction of labor in women with oligohydramnios.

OBJECTIVE: To prospectively evaluate the outcome of labor induction in women with oligohydramnios at term. METHODS: This was a prospective case-control study which included 120 consecutive patients with Amniotic Fluid Index (AFI) < or =5 undergoing labor induction. One hundred and sixteen patients with normal amniotic fluid matched for gestational age (+/- 3 days) and Bishop-score served as controls. Inclusion criteria were: requirement of labor induction, singleton pregnancy, nulliparity, Bishop score <5, gestational age > or =266. Preinduction treatment included the use of up to 3 successive doses of dinoprostone intracervical gel (0.5 mg). Vaginal dinoprostone (2 mg) and/or oxytocin were then applied to induction labor, if necessary. RESULTS: The rate of cesarean section in AFI < or = 5 group (38.3%) was not significantly different to that in control group (34.2%). The interval from induction to vaginal delivery was not significantly different for AFI < or =5 group (1499 +/- 895 min.) and control group (1398 +/- 852 min.). The changes in Bishop score evaluated at 6th and 12th hour after dinoprostone were not significantly different in control and AFI< or =5 group. More women in the latter group (11.7% vs 3.3%, Chi Square:4.86, p = 0.027) required the use of drugs in order to manage tachysystole/hyperstimulation allowing a OR = 3.83 (95%C.I. = 1.13-14.27). The length of stay at hospital was 4.2 +/- 1.8 days for AFI < or =5 group and 4.3 +/- 1.3 for control group. CONCLUSIONS: Oligohydranmios at term did not influence the outcome of induction of labour in nulliparous women with unfavorable cervix.     

Membrane sweeping versus dinoprostone vaginal insert in the management of pregnancies beyond 41 weeks with an unfavorable cervix.

OBJECTIVE: To determine the best method of cervical ripening to prevent postdate inductions in women with an unfavorable cervix at 41 weeks' gestation. STUDY DESIGN: Women presenting at 41 weeks' gestation with a Bishop score of < or = 4 received daily dinoprostone (Cervidil) vaginal inserts (group I) or daily membrane sweeping (group II). RESULTS: One-hundred and eighty-two women were prospectively randomized with 91 women in each arm. The women in group II, membrane sweeping, had Bishop scores significantly greater on admission for delivery (p < 0.001), had less time elapsed from admission to delivery (p = 0.018), and had fewer labor inductions at 42 weeks (p = 0.04) than the women in group I, the dinoprostone group. In addition, a greater number of women in group II were admitted in spontaneous labor (p = 0.006) than in group I. Total antenatal costs for the membrane sweeping group was $15,120 versus $59,540 for the dinoprostone group. CONCLUSION: Daily membrane sweeping was more effective than dinoprostone administration with fewer postdate inductions at one-fourth the cost.     

Effect of vaginal pH on efficacy of the controlled-release dinoprostone vaginal insert for cervical ripening/labor induction

Objective: To evaluate whether vaginal pH alters the efficacy of the controlled-release dinoprostone vaginal insert (Cervidil^®) for cervical ripening/labor induction. Methods: Thirty-four women with an unfavorable cervix undergoing labor induction were enrolled in this prospective, double-blind investigation. Vaginal pH and Bishop score assessments were made by an independent examiner. All women received preinduction with the dinoprostone vaginal insert 10 mg intravaginally for 12 h. Twelve hours later, oxytocin induction initiated according to the standardized protocol and outcome data were collected. Results: Mean (± SD) initial vaginal pH was 4.9 ± 0.5 for the study cohort. No significant differences were noted between women with a high vaginal pH (> 4.5, n = 18) and those with a low vaginal pH (≤ 4.5, n = 16) with respect to maternal age, parity, gestational age, or initial Bishop score. Similarly, Bishop score change over the preinduction interval (3.2 vs. 3.3), time to active labor (28.6 vs. 24.6 h) and time to delivery (33.7 vs. 31.4 h) were not significantly different between the low and the high pH groups, respectively. Linear regression analysis revealed no significant association between vaginal pH and Bishop score change during the preinduction interval, time to active labor, time to complete dilatation, or time to delivery. Conclusion: Vaginal pH does not appear to influence the efficacy of the controlled-released dinoprostone vaginal insert for cervical ripening/labor induction.     

Randomized comparison of oral misoprostol and oxytocin for labor induction in term prelabor membrane rupture

OBJECTIVES: To compare labor induction intervals between oral misoprostol and intravenous oxytocin in women who present at term with premature rupture of membranes. METHODS: One hundred eight women were randomly assigned to misoprostol 50 microg orally every 4 hours as needed or intravenous oxytocin. The primary outcome measure was time from induction to vaginal delivery. Sample size was calculated using a two-tailed alpha of 0.05 and power of 80%. RESULTS: Baseline demographic data, including maternal age, gestation, parity, Bishop score, birth weight, and group B streptococcal status, were similar. The mean time +/-standard deviation to vaginal birth with oral misoprostol was 720+/-382 minutes compared with 501+/-389 minutes with oxytocin (P = .007). The durations of the first, second, and third stages of labor were similar. There were no differences in maternal secondary outcomes, including cesarean birth (eight and seven, respectively), infection, maternal satisfaction with labor, epidural use, perineal trauma, manual placental removal, or gastrointestinal side effects. Neonatal outcomes including cord pH, Apgar scores, infection, and admission to neonatal intensive care unit were not different. CONCLUSION: Although labor induction with oral misoprostol was effective, oxytocin resulted in a shorter induction-to-delivery interval. Active labor intervals and other maternal and neonatal outcomes were similar.     

Effect of coital activity on onset of labor in women scheduled for labor induction: a randomized controlled trial

OBJECTIVE: To estimate the effect of coitus on the onset of labor. METHODS: Women with a nonurgent labor induction at term were recruited. Women randomly assigned to the advised-coitus group were encouraged to have sex to promote the onset of labor. Controls were neither encouraged nor discouraged regarding coitus. Participants kept a coital and orgasm diary until delivery, and standard obstetric care was provided to both groups. Primary outcomes were reported coitus and spontaneous labor. Secondary outcomes included reported orgasms, initial Bishop score at the admission for induction, preterm rupture of membranes, use of dinoprostone, oxytocin, or epidural, meconium-stained amniotic fluid, cesarean delivery, maternal fever, and neonatal morbidity. RESULTS: One hundred eight and 102 women randomly assigned to advised-coitus and control groups, respectively, were available for analysis. Women assigned to the advised-coitus group were more likely to report coital activity before delivery (60.2% compared with 39.6%, relative risk 1.5, 95% confidence interval 1.1-2.0; P=.004), but the spontaneous labor rate was no different (55.6% compared with 52.0%, relative risk 1.1, 95% confidence interval 0.8-1.4; P=.68). Cesarean delivery rate and neonatal and other secondary outcomes were also not different. CONCLUSION: Among women scheduled for labor induction who were advised to have sex, the increase in sexual activity did not increase the rate of spontaneous labor. CLINICAL TRIAL REGISTRATION: isrctn.org, http://isrctn.org, ISRCTN17998696     

Randomized comparison between intravaginal misoprostol and dinoprostone for cervical ripening and induction of labor.

OBJECTIVE: We sought to evaluate the efficacy and safety of intravaginal misoprostol and dinoprostone for labor induction. STUDY DESIGN: One hundred eighty-nine women with singleton term pregnancies and unfavorable cervices were randomly assigned to receive intravaginal misoprostol or dinoprostone. The outcome variables were change in Bishop score, time from application to active phase of labor and delivery, fetal and maternal morbidity, and the incidence of cesarean deliveries. RESULTS: The interval from application of the initial dose to the beginning of the active phase of labor was 9.8 +/- 5.8 and 14.2 +/- 10.2 hours (P <.01), and the interval from initial dose to delivery was 15.3 +/- 9.8 and 19.1 +/- 13.2 hours (P =.027) for the misoprostol and dinoprostone groups, respectively. There were no significant differences in Bishop score change, cesarean delivery rate, and the incidence of tachysystole, hypersystole, and hyperstimulation. No maternal and neonatal adverse effects were noted. CONCLUSION: Intravaginal misoprostol is more effective than intravaginal dinoprostone for labor induction in low-risk patients at term with unfavorable cervices.     

Randomized trial of concurrent oxytocin with a sustained-release dinoprostone vaginal insert for labor induction at term.

OBJECTIVE: The purpose of this study was to determine whether the concurrent administration of oxytocin with sustained-release dinoprostone results in shorter induction times when compared with oxytocin after the removal of the dinoprostone insert. STUDY DESIGN: Women with singleton pregnancies at > or = 36 weeks, vertex presentations, reactive nonstress tests, no prior uterine scar, intact membranes, and Bishop scores of < or = 6 were randomly assigned to receive oxytocin either immediately after placement of a sustained-release dinoprostone insert (immediate) or 30 minutes after its removal (delayed). The primary outcome was the time interval from induction to delivery. RESULTS: Seventy-one patients were enrolled (immediate, 34 patients; delayed, 37 patients). There were no differences between treatment groups in non-reassuring fetal heart tracings, excess uterine activity, and epidural use. The mean time from dinoprostone placement until delivery was 544 minutes, shorter in the immediate group (972 vs 1516 minutes; P =.001). The proportion of deliveries within 24 hours was higher (90% vs 53%; P =.002) in the immediate group. Cesarean delivery rates were similar between the immediate and delayed groups (16% vs 13%; P =.73). No adverse maternal or neonatal outcomes were observed with concurrent therapy. CONCLUSION: Oxytocin that is administered concurrently with sustained-release dinoprostone significantly shortens induction-to-delivery times and results in a higher proportion of vaginal deliveries of < or = 24 hours with no apparent adverse effects.     

Oral misoprostol for premature rupture of membranes at term

OBJECTIVE: The study was undertaken to compare the efficacy, safety, and maternal satisfaction of oral misoprostol and intravenous oxytocin for labor induction in women with premature rupture of membranes at term. STUDY DESIGN: One hundred five women were stratified by parity and randomly assigned to oral misoprostol 75 microg every 4 hours as needed to establish labor or to intravenous oxytocin. RESULTS: The induction to vaginal delivery time with oral misoprostol was 737 (+/-426) minutes compared with 573 (+/-318) minutes with oxytocin (P=.04). The incidence of hyperstimulation was lower in the misoprostol group (6.0% vs 27.1%, P=.005). Women were more likely to be very satisfied with their care in the misoprostol group (86.0% vs 63.4%, P=.02). CONCLUSION: In women at term with premature rupture of membranes, oral misoprostol resulted in a longer induction to vaginal delivery interval but increased maternal satisfaction and less hyperstimulation compared with intravenous oxytocin. Further research is needed to assess uncommon neonatal and maternal outcomes.     

A prospective randomized trial of labor induction with vaginal controlled-release dinoprostone inserts with or without oxytocin and misoprostol+oxytocin

OBJECTIVE: This study was designed in an aim to compare the efficacies of three labor induction methods, dinoprostone (PGE2) vaginal insert with or without concomittant oxytocin and misoprostol (PGE1) combined with oxytocin infusion. METHODS: This was a prospective observational trial of nulliparous women undergoing labor induction from December 2006 to January 2007. Inclusion criteria were: gestational age between 36 to 42 weeks, singleton cephalic presentation of the fetus, intact membrane and unfavorable cervical Bishop score < 6, and absence of spontaneous uterine contractions. Participants were then randomly assigned to preinduction cervical ripening with a dinoprostone vaginal insert (10 mg) administered into the posterior fornix for a total of 12 hours without oxytocin (group I); with oxytocin (group II), and with misoprostol (50 microg) intravaginally in the posterior fornix with repeat dosing at 6-hour intervals with a maximum dose of four with oxytocin (group III). RESULTS: A total number of 106 women met the inclusion criteria without distribution for 19 cases in group I, 44 and 43 cases in groups II and III, respectively. There were no statistically significant differences in terms of the demographic characteristics, indication of labor induction, interval from-induction-to-delivery, cardiotocographic abnormalities and neonatal outcomes and mode of deliveries among the three groups (p > 0.05). CONCLUSIONS: Three methods of labor induction were equally efficient in achieving succesful delivery without any maternal and fetal adverse outcomes.     

A randomized trial of misoprostol versus extra-amniotic sodium chloride infusion with oxytocin for induction of labor

OBJECTIVE: Our purpose was to compare the efficacy and safety of misoprostol and extra-amniotic sodium chloride infusion with oxytocin for induction of labor.Study Design: This randomized trial compared two methods of labor induction in women requiring cervical ripening. One hundred twenty-three women undergoing labor induction with a Bishop score < or =5 were randomly selected to receive either misoprostol, 50 microg intravaginally every 4 hours, or extra-amniotic sodium chloride infusion. The primary outcome variable was the time interval from induction to vaginal delivery. RESULTS: Sixty-one women received extra-amniotic sodium chloride infusion and 62 women received misoprostol. The mean time interval from the start of induction to vaginal delivery was 15.0 +/- 5.0 hours and 16.5 +/- 7.2 hours for the extra-amniotic infusion and misoprostol groups, respectively (P, not significant). The cesarean delivery rate was not significantly different between the 2 groups (32.8% for the extra-amniotic infusion group; 19.4% for the misoprostol group). Maternal and neonatal outcomes were similar between the 2 groups. CONCLUSIONS: Both methods of induction are equally efficacious and result in similar maternal and neonatal outcomes.     

Misoprostol for induction of labour at term: a more effective agent than dinoprostone vaginal gel.

OBJECTIVE: To compare the efficacy of vaginal misoprostol and dinoprostone vaginal gel for induction of labour at term. DESIGN: A single-blind randomised comparative trial. SETTING: Induction and labour wards of a UK teaching hospital. PARTICIPANTS: Two hundred and eleven pregnant women at term in whom induction of labour was indicated, and with no contra-indication to the use of prostaglandins for the induction of labour. INTERVENTION: The women were randomly assigned to receive vaginal administration of either misoprostol 50 microg four hourly (to a maximum of four doses) or dinoprostone gel 1 mg six hourly (to a maximum of three doses). MAIN OUTCOME MEASURES: Time from induction to delivery, oxytocin requirement in labour, analgesic requirement, mode of delivery, neonatal outcome. RESULTS: The misoprostol group had a highly significant reduction in median induction-delivery interval compared with the dinoprostone group (14.4 hours vs 22.9 hours; P < 0.00001). In addition, more women delivered after only one dose (77% vs 49%; P < 0.0001, OR 3.51, 95% CI 1.94-6.35), and within 12 and 24 hours. There was a reduced need for oxytocin augmentation in labour (21% vs 47%; P < 0.0001, OR 0.30, 95% CI 0.16-0.54). There was no difference in analgesia requirement in labour, or in mode of delivery. There were no adverse neonatal outcomes associated with the use of misoprostol. Women in the misoprostol group experienced more pain in the interval between induction and being given analgesia in labour, but this did not reach statistical significance. CONCLUSIONS: Misoprostol 50 microg vaginally is a more effective induction agent than 1 mg dinoprostone vaginal gel, with no apparent adverse effects on mode of delivery, or on the fetus. The higher pain scores in the misoprostol group must be balanced against the reduction in time spent having labour induced, and the reduction in need for intravenous oxytocin augmentation. Further randomised studies must continue to exclude the possibility of rare adverse side effects.     

Cervical ripening and induction of labor with misoprostol,dinoprostone gel,and a Foley catheter: a randomized trial of 3 techniques

OBJECTIVE: The purpose of this study was to compare the efficacy of 3 different techniques of cervical ripening and induction. STUDY DESIGN: Patients who required cervical ripening and induction were randomized to one of 3 groups: (1) supracervical Foley catheter and intravaginal dinoprostone gel, (2) supracervical Foley catheter and 100 microg oral doses of misoprostol, or (3) serial 100-microg oral doses of misoprostol. Intravenous oxytocin was administered when a protraction disorder of labor was identified. RESULTS: There were 339 women randomized. There was no significant difference in the time from first intervention to delivery in the 3 groups (P =.546). In each group, a similar percentage of women required oxytocin (P =.103). The rates of cesarean delivery were equivalent among the groups (P =.722). Rates of tachysystole were high but statistically equivalent among the 3 groups. There were no significant differences in Apgar scores or umbilical artery pH. CONCLUSION: Oral 100 microg serial doses of misoprostol, with or without the use of a supracervical Foley catheter, were equivalent to the use of a supracervical Foley catheter and serial 4-mg doses of dinoprostone gel for cervical ripening and the induction of labor.