Induction of labor in postterm pregnant women

We have studied the outcome of labor induction in 145 postterm pregnant women in whom gestational age was properly assessed by ultrasound scanning. The induction techniques were adapted to the cervical states of the patients. Seventy-five patients (32 nulliparous and 43 multiparous) with favorable cervical states were successfully induced with intravenous oxytocin. In this group the frequency of Caesarean section was 2%. Seventy patients (45 nulliparous and 25 multiparous) with unripe cervices received 0.5 mg PGE2 in viscous gel intracervically to prime the cervix and to induce labor; 38 (52%) were induced into labor after a single PGE2-gel application whereas 26 (48%) needed labor augmentation with intravenous oxytocin after PGE2-gel obtained cervical ripening. In 6 of the 20 patients the cervix did not ripen and the PGE2-gel application had then to be repeated. The frequency of cesarean sections was 11%. In 5 out of the 145 patients (4%) the fetuses had signs of intrauterine growth retardation (IUGR) as assessed by ultrasound scanning, and postmaturity as verified by pediatric examination at delivery. All these fetuses belonged to nulliparous women with unripe cervices and all had to be delivered instrumentally (3 by cesarean section and 2 by ventouse) indicating the fragility of these children. If postterm pregnancy is complicated by an unfavorable cervical state intracervical application of PGE2-gel seems to be an efficient method to prime the cervix and to induce labor. In most patients an uncomplicated vaginal delivery can be achieved by this procedure. However, nulliparous women with unfavorable cervices and signs of IUGR constitute a high risk group of patients at labor induction.     

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.     

Failed induction of labor despite sequential prostaglandin E2 therapy

Preinduction cervical ripening with prostaglandin E2 (PGE2) is useful in minimizing the chances for a failed induction of labor. The lack of sufficient cervical dilation despite PGE2 and oxytocin therapy is uncommon. This investigation was undertaken to determine reasons for any failed inductions in pregnancies with pregel Bishop scores 4 or lower and requiring delivery within 24 hours. Fifteen (12.1%) of 124 eligible patients had failed inductions despite two 2.5 mg intravaginal doses. A finding in all the failures was a very unfavorable cervix (pregel Bishop score 0 to 2). The need for preterm delivery (33 to 37 weeks) was a common finding in the presence of a very unfavorable cervix. The data suggest that complicated pregnancies requiring delivery within 24 hours and failing to respond to sequential PGE2 therapy in the presence of a very unfavorable cervix may benefit from cesarean section without a prolonged induction.     

Oxytocin-induced labor characteristics and uterine activity after preinduction cervical priming with prostaglandin E2 intracervical gel

Labor characteristics and quantitation of uterine activity resulting from oxytocin induction of labor after intracervical prostaglandin E2 (PGE2) gel priming have not been previously reported. Forty-seven women with modified Bishop scores of 5 or less received preinduction priming with 0.5 mg of intracervical PGE2 gel. Oxytocin was used to induce labor after priming, and uterine activity was quantitated. A matched group of control patients was managed identically but did not receive PGE2 gel. In the gel group, modified Bishop scores improved significantly and in two patients (4%), priming alone induced labor. No uterine hyperstimulation or fetal heart rate abnormalities occurred during priming. Cesarean sections for all indications and those for failed induction were less common in the gel group. The length of the active phase and the second stage of labor were significantly shorter in the gel group. Uterine activity was similar in both groups. The data suggest a primary cervical action of the gel.     

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.     

Open randomized comparison of prostaglandin E2 given by intracervical gel or vagitory for preinduction cervical ripening and induction of labor.

Intracervical application of prostaglandin E2 (PGE2) in a viscous gel was compared with conventional wax-based PGE2 vagitories (pessaries) for ripening of the cervix prior to induction of labor. A total of 226 healthy pregnant women at term were randomly allocated to receive intracervical gel with an effective dose of 0.5 mg (n = 116) or vagitories containing 2.5 mg PGE2 (n = 110). All women had a modified cervical score of less than or equal to 4. The numbers of cases contributed by each of the three centers were similar. There was no significant difference in parity, gestational length, maternal characteristics, indications for induction or preinduction cervical scores between the treatment groups. The rate of spontaneous birth was 71% in the gel group, compared with 69% in the vagitory group. Successful treatment was defined as active labor within 24 h or a change in cervical dilatation allowing artificial rupture of the membranes with subsequent progressive labor. The success rate was not significantly different in the gel group (82%) compared with the vagitory group (80%). There were no differences in the frequency of fetal distress, outcome of labor, assisted delivery rates or maternal side effects. The cervical scores were not different at 12 and 24 h after application. Intracervical gel and intravaginal application of PGE2 were similar in their efficacy and safety for ripening of the cervix and inducing labor at term.     

Balloon cervical ripening with extra-amniotic infusion of saline or prostaglandin E2: a double-blind, randomized controlled study

OBJECTIVE: To compare extra-amniotic infusion of diluted prostaglandin (PG) E2 solution with saline infusion in balloon cervical ripening and labor induction. METHODS: Women with pregnancy complications and Bishop scores of 3 or lower (n = 116) were assigned randomly to receive extra-amniotic infusion (1 mL/minute) of normal saline or PGE2 in saline (0.5 microg/mL) through a Foley catheter with a 30-mL inflated balloon. We induced labor using intravenous oxytocin only when labor had not developed by 6 hours after balloon expulsion. Analysis was by intent-to-treat. We assessed ripening efficiency and course of labor in women who had spontaneous balloon expulsion (n = 110) and trial of labor (n = 107), respectively. RESULTS: Ripening with PGE2 was associated with significantly shorter mean (+/- standard error of the mean [SEM]) time for balloon expulsion (4.7 +/- 0.4 versus 6.5 +/- 0.6 hours) and with significantly higher Bishop scores (P <.002), compared with ripening with saline. In the PGE2 group, rates of labor induction (15%) and oxytocin use (37%) were significantly lower than in the saline group (51% and 72%, respectively). The groups did not differ significantly in other labor abnormalities, labor duration, mode of delivery, birth weight, Apgar scores, and puerperal morbidity. CONCLUSION: Cervical ripening by extra-amniotic balloon and PGE2 infusion is faster and more effective than by balloon and saline infusion, resulting in a higher rate of spontaneous labor and a lower rate of oxytocin use.     

Induction of labor with intravenous oxytocin or vaginal PGE2 suppositories. A randomized study

Thirty-eight term pregnant women with a moderately unfavorable cervix (cervical score 4-5 p.) were randomly given intravenous oxytocin (Group A) or 3 mg PGE2 as a vaginal suppository (Group B) for labor induction. Eight out of 19 in Group A and 17 out of 19 in Group B gave birth vaginally within 24 h. The remaining 11 women in Group A had still an unfavorable cervix after 24 h. They were then given 3 mg PGE2 as a vaginal suppository and all but one had given birth vaginally without complications within 24 h. In Group B only 2 were still undelivered after 24 h. Both had a favorable cervix and were delivered vaginally within 12 h after intravenous infusion of oxytocin. The number of instrumental deliveries in Group A was one cesarean section and two vacuum extractions and in Group B three vacuum extractions. One woman in Group B reported nausea and vomiting and in one had strong uterine contractions in the second stage of labor. Otherwise no side effects were registered. All babies were born in good condition with Apgar scores greater than or equal to 7. In conclusion, vaginal application of 3 mg PGE2 as a suppository seems to be more effective than intravenous infusion of oxytocin for labor induction in women with half-ripened cervices, i.e. cervical scores of 4-5 p.     

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.     

Role of prostaglandin-induced cervical changes in labor induction

The role of the cervix in labor induction has been studied in a previous report. Cervical preparation by mechanical methods did not alter the course of induced labor. The same hypothesis is further elucidated in the present study using prostaglandin E2 vaginal suppositories for cervical preparation. Forty-seven pregnant women near term with Bishop scores of 4 or less were divided into three study groups: control subjects, oxytocin-treated patients, and prostaglandin group. A 12-hour preparation phase procedure was carried out to produce cervical and/or myometrial changes. All women had continuous measurement of uterine activity by an extraovular catheter. At the end of the preparation phase, the Bishop score was reevaluated, amniotomy carried out in all patients, and oxytocin infusion either started or continued. Although prostaglandin and oxytocin both significantly changed the cervix, oxytocin had the shortest induction-to-delivery interval, though the prostaglandin-treated group required lower concentrations of oxytocin. The authors conclude that with rigid control of Bishop score and timing of amniotomy and oxytocin infusion rates, prostaglandin-induced cervical changes alone did not uniquely benefit labor induction in the doses used, or within the time frame of the study.     

A comparative randomized study of oral prostaglandin E2 (PGE2) tablets and intravenous oxytocin in induction of labor in patients with premature rupture of membranes before 37 weeks of pregnancy

In a randomized prospective study, we compared the use of intravenous oxytocin with oral PGE2 tablets for stimulation of labor in cases of premature rupture of membranes (PROM) before term, where the onset of spontaneous labor did not occur within the first 3 h. This study represents the first of its kind in which oral PGE2 and oxytocin have been directly compared as oxytocic agents for PROM before 37 weeks. Labor induction was successful in 96% of patients in the PGE2 group compared with 84% in the oxytocin group. The incidence of cesarean section (CS) was 5% and 16% in the PGE2 and the oxytocin groups, respectively. While 10% of the CS were performed due to fetal bradycardia in the oxytocin group, none was performed in the PGE2 group despite the fact that the latter group had relatively lower Bishop scores. The data presented indicate that oral PGE2 is safe and effective in initiating active labor in healthy women at pre-term with PROM. Thus we recommend its use to induce labor 3 h after rupture of membranes before 37 weeks gestation.     

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.     

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 induction of labor by intracervical and extra-amniotic prostaglandin gel application in cases of intrauterine fetal death

In 42 patients with intrauterine fetal death between the 29th and 43rd week of gestation, a standard, 2-step procedure was employed to deliver the dead fetus. After priming with an intracervical application of PGF2 alpha- or PGE2-gel, labor was induced by extra-amniotic prostaglandin (PG) gel or oxytocin infusion while under epidural anesthesia. Intracervical PG application led to a significant improvement in the modified Bishop score from 1.3 to 7.6 after a mean of 8 h. In 20 patients labor and progressive dilatation of the cervix occurred after intracervical PG gel application alone. The average total therapy time was 18.1 h in patients treated with PGF2 alpha and 13.7 h in the PGE2-treated group. The average induction of labor to delivery intervals were 8.8 h in the PGF2 alpha- and 7.1 h in the PGE2-group. Gastrointestinal side effects were observed in only 5 patients. The combination of cervical ripening with intracervical PG gel application and induction of labor by extra-amniotic PG gel under epidural anesthesia is an efficient and safe method for treatment of intrauterine fetal death.     

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.     

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   

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。     

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. A double-blind randomized controlled study of prostaglandin E2 vaginal suppositories compared with intranasal oxytocin and with sequential treatment

In a double-blind randomized controlled study of 300 women, 150 primiparas and 150 multiparas, induction of labor by means of vaginal suppositories containing 3 mg prostaglandin E2 (PGE2) was compared with the conventional method of intranasal oxytocin and with a combined method of 3 mg PGE2 vaginal suppositories alternating with intranasal oxytocin. In the PGE2 group the intensity of delivery was significantly greater than in the oxytocin group, among both primiparas and multiparas and among the patients with ripe and unripe cervix. The efficiency of the combined treatment could no be evaluated because of the high intensity of delivery during the first 24 hours. There were no maternal side effects, and no significant difference in the frequencies of failed induction and cesarean section.     

Cervical priming and/or induction by intracervical application of PGE2-gel in term patients with preeclampsia and unfavorable cervical states

92 preeclamptic women with unfavorable cervical states were treated with intracervical application of prostaglandin E2 (PGE2) in gel for cervical priming and/or labor induction. 55 (60%) were delivered after a single PGE2-gel application. In 27 (29%) the cervical state was improved after 24 h and labor could be induced by oxytocin infusion. Thus, 89% of the women were delivered within 48 h after a single PGE2-gel application. In 10 women (11%) a second PGE2-gel application had to be done before oxytocin infusion. The frequency of cesarean sections was low (5%). No case of uterine hypertonus was seen. No gastrointestinal side effects were observed. All newborn infants had an apgar score at 5 min of more than 7 and were in good condition.